Nokea
A client with cancer has been placed on TPN. The nurse notes air entering the client via the central line. Which initial action is most appropriate?
- A. Notify the physician.
- B. Elevate the head of the bed.
- C. Place the client in the left lateral decubitus position.
- D. Stop the TPN and hang D51/2 NS.
Correct Answer: C
Rationale: The client is at risk for an air embolus. Placing the client in this position displaces air away from the right ventricle. Answers B and D would not help, so they are incorrect, and answer A would not be done first, so it's incorrect.
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A client with a history of increased intracranial pressure is admitted to the hospital for severe headaches. The client suddenly vomits and states, 'That's weird, I didn't even feel nauseated.' Which action should the nurse take next?
- A. Document the amount of emesis
- B. Lower the head of the bed
- C. Notify the supervising registered nurse
- D. Offer an antinausea medication
Correct Answer: C
Rationale: Sudden vomiting without nausea in increased ICP suggests worsening pressure, requiring immediate RN notification (C). Documentation (A), lowering the bed (B), and antiemetics (D) are secondary.
The mother is concerned that her 6-year-old child is eating dirt every day. The nurse is most concerned about which of the following?
- A. The child may not be getting enough to eat.
- B. The child may have lead poisoning.
- C. This is normal childhood behavior.
- D. The child may have iron deficiency anemia.
Correct Answer: B
Rationale: Pica, such as eating dirt, raises concern for lead poisoning, especially in children, as contaminated soil may contain lead, posing neurological risks.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
Which behavioral characteristic describes the domestic abuser?
- A. Alcoholic
- B. Over confident
- C. High tolerance for frustrations
- D. Low self-esteem
Correct Answer: D
Rationale: Low self-esteem. Batterers were usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, and have a great need to exercise control or power over their partners.
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
- A. 1/2 cup orange juice
- B. Dry, sweetened cereal
- C. Raw carrot sticks
- D. Slice of cheese
Correct Answer: D
Rationale: A slice of cheese (D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (A) is high in sugar, sweetened cereal (B) lacks nutritional value, and raw carrot sticks (C) pose a choking hazard.