Nokea
A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?
- A. Perform a blind finger sweep.
- B. Turn the client to the side.
- C. Insert an oral airway.
- D. Administer the abdominal thrust maneuver.
Correct Answer: D
Rationale: The correct answer is D: Administer the abdominal thrust maneuver. This action should be taken first because it is the appropriate intervention for a conscious individual with an airway obstruction. The abdominal thrust maneuver helps dislodge the foreign body by creating pressure to expel it. Performing a blind finger sweep (A) can push the object further down the airway. Turning the client to the side (B) may not effectively clear the airway obstruction. Inserting an oral airway (C) could worsen the obstruction if not inserted correctly. Therefore, administering the abdominal thrust maneuver is the priority to clear the airway obstruction in a conscious individual.
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A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: The correct answer is 0.2 mL. To calculate this, divide the desired dose (2 mg) by the concentration (10 mg/mL). This gives 0.2 mL. The other choices are incorrect because: A) 2 mL would be an overdose; B) 0.02 mL is too small a dose; C) 20 mL is an overdose; D) 0.02 mL is too small a dose; E) 0.02 mL is too small a dose; F) 20 mL is an overdose; G) 2 mL would be an overdose.
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
- A. Hypophosphatemia
- B. Hyperkalemia
- C. Hypercalcemia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In prerenal AKI, decreased blood flow to the kidneys leads to reduced filtration and impaired excretion of potassium, resulting in hyperkalemia. Hypophosphatemia (A), hypercalcemia (C), and hypernatremia (D) are not typically associated with prerenal AKI. In prerenal AKI, there is usually no significant change in phosphate levels, calcium levels are typically normal or low due to volume depletion, and sodium levels may be normal or decreased due to reduced renal perfusion.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Generalized urticaria.
- B. Distended jugular veins.
- C. Blood pressure 184/92 mm Hg.
- D. Bilateral flank pain.
Correct Answer: A
Rationale: The correct answer is A: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. The release of histamine during the reaction causes itching and skin rash. Distended jugular veins (B) are more indicative of fluid overload or heart failure. Blood pressure of 184/92 mm Hg (C) is elevated but not specific to an allergic reaction. Bilateral flank pain (D) may suggest kidney issues or musculoskeletal problems, not necessarily related to an allergic reaction.
A nurse is preparing to administer clindamycin palmitate 225 mg PO every 8 hours to a client. The amount available is clindamycin palmitate oral suspension 75 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 15
Rationale: Correct Answer: 15 mL
Rationale: To calculate the mL to administer, first determine the total daily dose (675 mg). Divide this by the concentration of the oral suspension (75 mg/5 mL) to get the total mL per day (45 mL). Divide this by the number of doses per day (3) to get the mL per dose (15 mL).
Summary:
A: Incorrect, as it does not align with the correct calculation.
B-G: Irrelevant since the correct calculation method indicates 15 mL is the appropriate answer.
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.