Nokea
A client with advanced Alzheimer's disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?
- A. Cough
- B. Tremors
- C. Diarrhea
- D. Pitting edema
Correct Answer: B
Rationale: Haloperidol, an antipsychotic, can cause extrapyramidal side effects like tremors, which are common and indicate a neurological side effect.
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The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:
- A. Uncompensated respiratory acidosis
- B. Uncompensated metabolic acidosis
- C. Compensated respiratory acidosis
- D. Compensated metabolic acidosis
Correct Answer: C
Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.
The nurse is caring for a client with a wound with purulent, foul-smelling drainage. A wound culture is ordered. Which describes the correct collection technique?
- A. clean the wound with normal saline before obtaining specimen
- B. allow 24 hours for antibiotic therapy to take effect before sampling
- C. obtain the specimen from the drainage at the bottom of the wound
- D. culture the outer surface around the wound before collecting exudate
Correct Answer: A
Rationale: Cleaning the wound with saline removes surface contaminants, ensuring an accurate culture from viable tissue.
The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
- A. Safflower oil
- B. Sunflower oil
- C. Coconut oil
- D. Canola oil
Correct Answer: C
Rationale: Coconut oil is high in saturated fats, which raise LDL cholesterol, making it unsuitable for a low-cholesterol diet.
The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
- A. Allow the client to keep the plant
- B. Place the plant by the window
- C. Water the plant for the client
- D. Tell the family members to take the plant home
Correct Answer: D
Rationale: A low WBC (neutropenia) increases infection risk, so the plant, which may harbor bacteria or fungi, should be removed.
During which stage of injury repair does the wound show evidence of erythema and edema, and phagocytosis begins?
- A. Proliferation
- B. Inflammation
- C. Hemostasis
- D. Maturation
Correct Answer: B
Rationale: The inflammation stage (B) involves erythema, edema, and phagocytosis as the body responds to injury. Other stages (A, C, D) have different processes.