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A nurse is caring for a patient who is postoperative following abdominal surgery. The nurse discovers a loop of bowel protruding through an opening in the surgical incision. What should the nurse do? What should the nurse do for a protruding bowel?
- A. Gently reinsert the bowel back into the patient's wound.
- B. Place the head of the patient's bed in the flat position.
- C. Apply moistened sterile gauze to the site.
- D. Position the patient on his left side.
Correct Answer: C
Rationale: The correct answer is C: Apply moistened sterile gauze to the site. This is the correct action because it helps to keep the exposed bowel moist, which is crucial to prevent drying and potential damage. Reinserting the bowel (choice A) may cause further harm and should only be done by a surgeon. Placing the head of the bed flat (choice B) can increase intra-abdominal pressure and worsen the situation. Positioning the patient on his left side (choice D) does not address the immediate need to protect the exposed bowel. Applying moistened gauze is the best initial action to protect the bowel while awaiting further medical intervention.
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A nurse in an emergency department is caring for a patient who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. What prescription should the nurse anticipate from the provider? What prescription should the nurse anticipate for DKA?
- A. Glucocorticoid medications.
- B. Dextrose 5% in 0.45% sodium chloride.
- C. Oral hypoglycemic medications.
- D. 0.9% sodium chloride IV bolus.
Correct Answer: D
Rationale: The correct answer is D: 0.9% sodium chloride IV bolus. In DKA, the primary concern is severe dehydration and electrolyte imbalances due to high blood glucose levels. 0.9% sodium chloride helps to rehydrate the patient and correct electrolyte imbalances. Glucocorticoids (A) are not typically used in the treatment of DKA. Dextrose 5% in 0.45% sodium chloride (B) would worsen hyperglycemia. Oral hypoglycemic medications (C) are not appropriate for managing acute DKA. Therefore, the nurse should anticipate the prescription of 0.9% sodium chloride IV bolus to address the immediate needs of the patient with DKA.
A nurse is caring for a patient who has a new prescription for clonazepam. Which of the following instructions should the nurse include? What instructions should the nurse include for clonazepam?
- A. Avoid alcohol consumption.
- B. Take the medication with food.
- C. Increase fluid intake.
- D. Report any weight gain.
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol consumption. Clonazepam is a central nervous system depressant and can cause additive sedative effects when combined with alcohol, leading to increased drowsiness and impaired coordination. This can be dangerous and increase the risk of accidents or overdose. Therefore, it is essential for the nurse to instruct the patient to avoid alcohol consumption while taking clonazepam.
For the other choices:
B: Taking the medication with food is not specifically required for clonazepam administration.
C: Increasing fluid intake is not directly related to clonazepam use.
D: Reporting any weight gain is important for some medications, but it is not a specific concern with clonazepam.
Overall, the key instruction for the nurse to provide is avoiding alcohol consumption to ensure the safe and effective use of clonazepam.
Nurses’ Notes at 0700hrs
The client appears fatigued and reports a persistent headache. He has been experiencing muscle aches throughout his body. He also complains of a sore throat and has had a fever for the past two days. The client’s skin is warm to the touch and he appears slightly dehydrated.
Vital Signs at 0700hrs
• Temperature: 39.5°C (103.1°F)
• Blood pressure: 128/56 mm Hg
• Heart rate: 112/min
• Respiratory rate: 22/min
• SaO2: 96% on room air
Diagnostic Results at 0700hrs
• Complete blood count shows elevated white blood cells
• Throat culture has been sent to the lab for analysis
• Chest X-ray pending
A nurse is caring for a 45-year-old male client in the emergency department. The client was admitted at 0700hrs with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.The nurse is preparing to administer an antibiotic to the client. Which of the following actions should the nurse take? (Select all that apply)
- A. Wear a mask when caring for the client.
- B. Encourage the client to increase fluid intake.
- C. Place the client in a private room.
- D. Place the client on contact precautions.
- E. Monitor the client's temperature every 4 hours.
- F. Check the client's allergy history before administering the antibiotic.
- G. Educate the client about the importance of completing the full course of antibiotics.
Correct Answer: B,E,F,G
Rationale: The correct actions the nurse should take are to encourage the client to increase fluid intake, monitor the client's temperature every 4 hours, check the client's allergy history before administering the antibiotic, and educate the client about the importance of completing the full course of antibiotics.
Encouraging fluid intake helps maintain hydration and aids in the body's recovery. Monitoring temperature helps assess the client's response to treatment. Checking allergy history is crucial to prevent adverse reactions. Educating the client about completing the full course of antibiotics ensures effective treatment and prevents antibiotic resistance.
Wearing a mask (choice A) is not necessary for this situation unless the client is suspected of having a contagious respiratory illness. Placing the client in a private room (choice C) and placing the client on contact precautions (choice D) are not indicated unless the client is diagnosed with a specific contagious infection, which is not mentioned in the scenario.
A nurse is preparing to administer fluoxetine 40 mg PO daily. The available medication is fluoxetine 20 mg/mL. How many mL should the nurse administer? How many mL of fluoxetine should the nurse administer?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: To calculate the mL of fluoxetine to administer, use the formula: desired dose (40 mg) / stock dose (20 mg/mL) = mL to administer. Therefore, 40 mg / 20 mg/mL = 2 mL. This is why choice B (2 mL) is correct. Choice A (1 mL) is incorrect as it does not provide the full dose. Choices C (3 mL) and D (4 mL) are incorrect as they exceed the required dose.
A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings would indicate that the treatment has been effective? Which finding indicates effective cool mist tent treatment?
- A. Decreased stridor
- B. Decreased temperature
- C. Barking cough
- D. Improved hydration
Correct Answer: A
Rationale: The correct answer is A: Decreased stridor. Stridor is a high-pitched sound produced by turbulent airflow in the upper airway, which indicates airway obstruction. In acute laryngotracheobronchitis, the airway is inflamed and narrowed, leading to stridor. Placing the toddler in a cool mist tent helps reduce airway inflammation and swelling, leading to improved airflow and decreased stridor. Therefore, a decrease in stridor would indicate that the treatment has been effective.
Summary of Incorrect Choices:
B: Decreased temperature - This choice does not directly relate to the effectiveness of the cool mist tent treatment for laryngotracheobronchitis.
C: Barking cough - Barking cough is a characteristic symptom of croup, which is present in acute laryngotracheobronchitis. It does not specifically indicate the effectiveness of the cool mist tent treatment.
D: Improved hydration - While hydration is important in managing respiratory conditions