Nokea
A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?
- A. Vomiting, heart rate 120, chest pain
- B. Nausea, mild headache, bradycardia
- C. Respirations 16, heart rate 62, diarrhea
- D. Temp 101°F, tachycardia, respirations 20
Correct Answer: A
Rationale: Disulfiram causes a severe reaction with alcohol, including vomiting, tachycardia (HR 120), and chest pain due to acetaldehyde accumulation, making these symptoms most indicative.
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An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
The nurse is evaluating cerebral perfusion outcomes for a client with a subdural hematoma. The nurse evaluates which of the following as a favorable outcome for this client?
- A. Arterial blood gas POâ‚‚ of 98
- B. Increase in lethargy
- C. Pupils slow to react to light
- D. Temperature of 101°F
Correct Answer: A
Rationale: An arterial blood gas POâ‚‚ of 98 indicates adequate oxygenation, supporting cerebral perfusion, which is a favorable outcome for a subdural hematoma.
A new graduate nurse completes her first full shift with her preceptor. It was a long, overwhelming day and the new nurse takes a deep breath and says to herself, 'You can do this! Nursing will be a challenge but you are up for it and tomorrow is a new day.' This type of communication is
- A. intrapersonal.
- B. horizontal.
- C. interpersonal.
- D. vertical.
Correct Answer: A
Rationale: Intrapersonal communication is self-talk, as the nurse reflects and motivates herself.
The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:
- A. Fraud
- B. Malpractice
- C. Negligence
- D. Tort
Correct Answer: A
Rationale: Falsifying medical records, such as charting unadministered medications, constitutes fraud.
Which of the following roommates would be most suitable for the client with myasthenia gravis?
- A. A client with hypothyroidism
- B. A client with Crohn's disease
- C. A client with pylonephritis
- D. A client with bronchitis
Correct Answer: A
Rationale: Hypothyroidism poses no infection risk, unlike pyelonephritis or bronchitis.