Nokea
A nurse is caring for a client who has just undergone an ileostomy procedure. The nurse expects how much drainage from the ileostomy during the first 24 hours post-op?
- A. 650 mL
- B. 800 mL
- C. 1,500 mL
- D. 3,500 mL
Correct Answer: B
Rationale: Ileostomy drainage in the first 24 hours post-op is typically 500-1,000 mL due to liquid stool output. 800 mL is the most reasonable estimate.
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The nurse is auscultating a client's breath sounds. Low-pitched grating and rubbing are noted on inhalation and exhalation. What will the nurse chart under assessment findings?
- A. ronchi
- B. stridor
- C. friction rub
- D. fine crackles
Correct Answer: C
Rationale: Low-pitched grating/rubbing sounds indicate a pleural friction rub, often due to pleural inflammation.
A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is
- A. monitor client for bradycardia and respiratory depression.
- B. prepare client for synchronized cardioversion.
- C. monitor client for tachycardia and hyperventilation.
- D. prepare client for Swan catheter.
Correct Answer: A
Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.
The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:
- A. Cover the defect with a moist, sterile saline gauze
- B. Place the infant in a supine position
- C. Feed the infant slowly
- D. Measure the intake and output
Correct Answer: A
Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.
A schizophrenic client has been taking haloperidol (Haldol) for 20 months and has developed moderate extrapyramidal symptoms (EPS). The nurse anticipates the physician will likely prescribe what medication for EPS?
- A. flumazenil (Anexate)
- B. donepezil (Aricept)
- C. naloxone (Narcan)
- D. benztropine (Cogentin)
Correct Answer: D
Rationale: Benztropine, an anticholinergic, treats EPS (e.g., dystonia, parkinsonism) caused by antipsychotics like haloperidol.
The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:
- A. Take aspirin for discomfort
- B. Avoid bending over to put on his shoes
- C. Remove the eye shield before going to sleep
- D. Continue showering as usual
Correct Answer: B
Rationale: Avoiding bending over prevents increased intraocular pressure post-cataract surgery.