Nokea
A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
- A. Decrease the infusion rate on the IV.
- B. Document that the client experienced an anaphylactic reaction to the medication.
- C. Change the IV infusion site.
- D. Apply cold compresses to the neck area.
Correct Answer: A
Rationale: The correct answer is A: Decrease the infusion rate on the IV. Flushing of the neck and tachycardia are common signs of "Red Man Syndrome," a potential adverse reaction to vancomycin infusion. Decreasing the infusion rate can help alleviate these symptoms. Documentation (B) of an anaphylactic reaction is inaccurate because these symptoms are not indicative of an anaphylactic reaction. Changing the IV site (C) is unnecessary as the symptoms are likely due to the medication itself. Applying cold compresses (D) is not effective for this reaction.
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A nurse is preparing to administer ciprofloxacin to a client. The nurse should identify that the medication is treatment for exposure to which of the following agents?
- A. Smallpox
- B. Anthrax
- C. Ebola virus
- D. Sarin gas
Correct Answer: B
Rationale: The correct answer is B: Anthrax. Ciprofloxacin is an antibiotic commonly used to treat anthrax, which is a bacterial infection caused by Bacillus anthracis. The rationale behind this choice is that ciprofloxacin is effective in treating anthrax infections by inhibiting the growth of the bacteria. Smallpox (A), Ebola virus (C), and Sarin gas (D) are not treated with ciprofloxacin as they are caused by a virus, a different virus, and a nerve gas, respectively.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
- A. Pruritus
- B. Swollen gums
- C. Dysphagia
- D. Urinary hesitancy
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia, difficulty swallowing, is a priority finding in an older adult male as it can lead to aspiration and malnutrition. The nurse needs to address this promptly to prevent complications. Pruritus (choice A) is itching and can be managed. Swollen gums (choice B) may indicate dental issues but are not immediately life-threatening. Urinary hesitancy (choice D) can be indicative of a urinary problem but does not pose an immediate risk compared to dysphagia.
A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
- A. Assist the client to sit upright in a chair for 4 hours at a time.
- B. Expect clear drainage on the spinal dressing.
- C. Log roll the client every 2 hours.
- D. Perform neurological checks every 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Log roll the client every 2 hours. This action is crucial for preventing complications such as pressure ulcers and maintaining spinal alignment post spinal fusion surgery. Log rolling helps to keep the spine in proper alignment and reduces the risk of injury to the surgical site. Assisting the client to sit upright for 4 hours at a time (choice A) can put excessive pressure on the surgical site and hinder the healing process. Expecting clear drainage on the spinal dressing (choice B) is not appropriate as drainage may vary and is not necessarily an indicator of infection. Performing neurological checks every 8 hours (choice D) is important but should be done more frequently in the immediate postoperative period.
A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
- A. Wrap the stump with an elastic bandage in a figure-eight configuration.
- B. Remove the elastic bandage and re-wrap the stump once per day.
- C. Perform passive range of motion exercises once daily.
- D. Secure the elastic bandage to the lowest joint.
Correct Answer: A
Rationale: The correct answer is A: Wrap the stump with an elastic bandage in a figure-eight configuration. This action helps reduce swelling, provide support, and shape the stump for prosthesis fitting. Wrapping in a figure-eight pattern ensures even compression and prevents constriction. Choice B is incorrect as frequent re-wrapping can disrupt wound healing. Choice C is unnecessary and may cause discomfort. Choice D is incorrect as securing the bandage at the lowest joint can lead to constriction and hinder circulation.