Nokea
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers to the left foot
Correct Answer: A
Rationale: Foscarnet requires monitoring for toxicity, making this client a priority.
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The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
- A. Within 72 hours of delivery
- B. Within 1 week of delivery
- C. Within 2 weeks of delivery
- D. Within 1 month of delivery
Correct Answer: A
Rationale: RhoGam must be administered within 72 hours postpartum to prevent Rh sensitization.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.
A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
- A. Adjust the room temperature
- B. Give a bolus of IV fluids
- C. Start O2
- D. Administer meperidine (Demerol) 75 mg IV push
Correct Answer: C
Rationale: A pulse oximetry of 92 indicates hypoxemia, so administering oxygen is the priority to improve oxygenation and prevent further sickling.
The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
- A. Constipation
- B. Hyperphosphatemia
- C. Hypomagnesemia
- D. Diarrhea
Correct Answer: A
Rationale: Calcium carbonate can cause constipation, a common side effect, due to its effect on gastrointestinal motility.
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.
- A. Immediately stop the infusion.
- B. Discontinue the PCA pump.
- C. Administer naloxone per standing orders.
- D. Administer supplementary oxygen.
- E. File an incident report.
Correct Answer: A,C,D,E
Rationale: Opioid overdose requires stopping the infusion (A), administering naloxone (C) to reverse effects, providing oxygen (D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (B) is not immediate.