Nokea
A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following?
- A. Induces sleep.
- B. Stimulates the client's appetite.
- C. Relieves muscular spasticity.
- D. Reduces the urine bacterial count.
Correct Answer: C
Rationale: Baclofen is a muscle relaxant used in MS to relieve spasticity, its primary therapeutic effect. It does not induce sleep, stimulate appetite, or reduce bacterial counts.
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Several clients have come to the emergency department after a possible bioterrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply.
- A. Violent vomiting.
- B. Severe diarrhea.
- C. Abdominal pain.
- D. Sensory neuropathy.
- E. Persistent cough.
Correct Answer: A,B,C
Rationale: Arsenic poisoning typically presents with acute gastrointestinal symptoms such as violent vomiting, severe diarrhea, and abdominal pain due to its toxic effects on the digestive system. Sensory neuropathy and persistent cough are less common immediate symptoms.
A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the chart. Which action would be most appropriate for the nurse to implement?
- A. Wearing a protective gown and particulate respiratory mask when completing treatments.
- B. Washing hands before and after entering the room.
- C. Restricting visitors.
- D. Contacting the physician for an order for hematopoietic factors such as erythropoietin (Epogen, Procrit).
Correct Answer: B
Rationale: With a low white blood cell count (1,600/mm³) and absolute neutrophil count (<1,000/mm³), hand washing before and after entering the room is critical to prevent infection in this neutropenic client.
The nurse is preparing to insert a peripheral vascular access device. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Apply sterile dressing over the intravenous site.
- B. Clean the selected area using an alcohol-based 2% chlorhexidine solution using friction for 30 seconds.
- C. Place the tourniquet 10 to 15 cm (4-6 inches) above the proposed site.
- D. Insert the intravenous catheter at a 15 to 30 degree angle.
- E. Advance the catheter until a flash of blood is seen, then advance the catheter into the vein while removing the needle.
- F. Palpate vein at intended insertion site by pressing downward.
- G. Release tourniquet temporarily.
Correct Answer: C,F,G,B,D,E
Rationale: The correct order ensures proper vein selection, site preparation, catheter insertion, and securement while minimizing complications.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to:
- A. Open and dilate blocked coronary arteries.
- B. Assess the extent of arterial blockage.
- C. Bypass obstructed vessels.
- D. Assess the functional adequacy of the valves and heart muscle.
Correct Answer: B
Rationale: Cardiac catheterization in unstable angina assesses the extent of coronary artery blockage to guide interventions like angioplasty or bypass surgery.