Nokea
A client with a history of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following adverse effects?
- A. Increased infection risk.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Etanercept, a biologic, increases infection risk due to immunosuppression.
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A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
- A. 1 cup of lentils
- B. 1 cup of sunflower seeds
- C. 1/2oz of hard cheese
- D. 2 poached eggs
Correct Answer: A
Rationale: Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
- A. Performing oral care every 4 hours.
- B. Elevating the head of the bed to 30-45 degrees.
- C. Administering prophylactic antibiotics.
- D. Suctioning the endotracheal tube every 2 hours.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
- A. Sterile items ONLY are placed on the sterile field.
- B. The nurse must keep the sterile field below waist level.
- C. Coughing or sneezing over the sterile field contaminates the sterile field.
- D. The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
- E. Moisture and wetness contaminate the sterile field.
- F. Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained
Correct Answer: A,C,E
Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).
The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antepartal unit and has the following orders and tasks to complete prior to 7 a.m. The nurse should complete the tasks in which order?
- A. Check documentation, final check of each client.
- B. Fetal monitor strip for 1/2 hour q shift.
- C. Magnesium sulfate drawn at 6 a.m.
- D. Accucheck and sliding scale insulin due at 7, 11, 4, and hs.
Correct Answer: D,G,F,A
Rationale: To manage time effectively: Check documentation and final client checks at 6:30 to ensure all records are complete (A); perform the fetal monitor strip from 6:00 to 6:30 to meet the half-hour requirement (F); draw magnesium sulfate at 6:00 to align with the ordered time (G); perform Accucheck and insulin at 7:00 as per the schedule (D).
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client's apical pulse is 58 bpm. What should the nurse do next?
- A. Administer the dose as ordered
- B. Withhold the dose and notify the physician
- C. Reduce the dose by half
- D. Recheck the pulse in 30 minutes
Correct Answer: B
Rationale: Digoxin is typically withheld if the apical pulse is below 60 bpm in adults, as bradycardia may indicate toxicity. The physician should be notified for further evaluation.