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A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which physician prescription would the nurse question?
- A. D5W at 200 mL/hr
- B. Demeclocycline (Declomycin) 150 mg Q6h
- C. Daily weights
- D. Intake and output Q4h
Correct Answer: A
Rationale: D5W at 200 mL/hr is inappropriate for SIADH, as it can worsen hyponatremia by adding free water. The other options are appropriate for monitoring and treating SIADH.
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The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
- A. Upper-gastrointestinal x-ray
- B. Gastric analysis
- C. Endoscopy
- D. Barium studies
Correct Answer: C
Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
- A. Inspiratory stridor and harsh cough
- B. Strident cough and drooling
- C. Wheezing and intercostal retractions
- D. Expiratory wheezing and nonproductive cough
Correct Answer: A
Rationale: Acute laryngotracheobronchitis (croup) is characterized by inspiratory stridor and a harsh, barking cough due to upper airway inflammation and narrowing.
The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?
- A. discontinue the oxytocin infusion
- B. increase the oxytocin infusion rate
- C. decrease the oxytocin infusion rate by half
- D. reposition the client into a high-Fowler's position
Correct Answer: A
Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.
A nursing instructor demonstrates to several students how to wrap an amputated limb in a bandage using a figure eight technique. Which of the following correctly states the benefits of this technique? Select all that apply.
- A. prevents blood clots from forming
- B. reduces post-operative swelling
- C. minimizes pain and discomfort
- D. prevents exposure to air
Correct Answer: B,C
Rationale: The figure-eight technique reduces swelling (B) by promoting venous return and minimizes pain (C) by stabilizing the limb. It does not prevent clots (A) or air exposure (D).
The nurse is admitting a client with a diagnosis of severe malignant catatonia to the in-patient psychiatric unit. Under which condition would the nurse support the use of electroconvulsive therapy (ECT) as a first-line treatment?
- A. The client is in the first trimester of pregnancy.
- B. The client is gainfully employed.
- C. The client lives in an assisted living facility.
- D. The client is over 50 years of age.
Correct Answer: C
Rationale: ECT may be considered first-line for severe malignant catatonia in a controlled setting like an assisted living facility, where monitoring is feasible. Pregnancy and age are contraindications or require caution, and employment is irrelevant.