Nokea
A nurse is caring for a patient who is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent ventilator-associated pneumonia? Which action prevents ventilator-associated pneumonia?
- A. Perform oral care every 12 hours.
- B. Keep the head of the bed elevated to 30-45 degrees.
- C. Administer antibiotics prophylactically.
- D. Change the ventilator circuit daily.
Correct Answer: B
Rationale: The correct answer is B: Keep the head of the bed elevated to 30-45 degrees. Elevating the head of the bed helps prevent aspiration, which is a significant risk factor for ventilator-associated pneumonia. This position promotes proper lung expansion and drainage of secretions, reducing the likelihood of bacterial growth in the lungs. Performing oral care every 12 hours (A) is important for oral hygiene but does not directly prevent ventilator-associated pneumonia. Administering antibiotics prophylactically (C) can lead to antibiotic resistance and is not recommended routinely. Changing the ventilator circuit daily (D) is important for infection control but does not directly prevent ventilator-associated pneumonia.
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A nurse in a coronary care unit is admitting a patient who has had CPR following a cardiac arrest. The patient is receiving lidocaine IV at 2 mg/min. When the patient asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? Why is the patient receiving lidocaine?
- A. Relieves pain.
- B. Slows intestinal motility.
- C. Dissolves blood clots.
- D. Prevents dysrhythmias.
Correct Answer: D
Rationale: The patient is receiving lidocaine to prevent dysrhythmias after experiencing a cardiac arrest. Lidocaine is a class IB antiarrhythmic drug that stabilizes the cardiac cell membrane, reducing the likelihood of abnormal electrical activity and dysrhythmias. It does not relieve pain, slow intestinal motility, or dissolve blood clots. Therefore, the correct answer is D, as it directly addresses the purpose of administering lidocaine in this specific clinical scenario.
A nurse is caring for a patient hospitalized for the treatment of severe depression. Which of the following nursing approaches should be included in the patient's care plan? Which approach should be included for severe depression?
- A. Spend time sitting with the patient.
- B. Offer the patient choices of activities.
- C. Establish a patient relationship.
- D. Explore the truth of the patient's statements.
Correct Answer: A
Rationale: The correct answer is A: Spend time sitting with the patient. Spending time with the patient demonstrates empathy, support, and a willingness to listen, which are crucial for patients with severe depression. It helps build a therapeutic relationship and provides emotional comfort. Choice B focuses more on autonomy and may not address the patient's emotional needs. Choice C is important but is a broad concept that is encompassed by spending time with the patient. Choice D may come off as confrontational and potentially exacerbate the patient's distress.
Nurse's Notes & Physical Examination
• The client is found attempting to climb out of bed, stating, "People are trying to hurt me." They are highly agitated and disoriented, attempting to remove IV lines. The client's behavior is erratic, and they require constant supervision. The skin is now cool and pale, with poor capillary refill. Respirations are labored, and the client is using accessory muscles to breathe. Lung sounds have deteriorated, with coarse crackles heard throughout. The abdomen is firm, and the client expresses significant discomfort. The urinary catheter output has decreased, and urine appears concentrated.
Vital Signs
• Blood Pressure: 100/64 mm Hg
• Temperature: 37.3° C (99.1° F)
• Pulse: 110/min
• Respirations: 28/min
Diagnostic Results
• Hemoglobin: 12.5 g/dL
• Hematocrit: 38.0%
• AST: 52 units/L
• ALT: 49 units/L
Provider's Prescriptions
• Soft wrist restraints if necessary.
• Immediate reassessment and adjustment of care plan.
2100 hrs - Critical Incident
A nurse is providing discharge teaching to a client recently diagnosed with a latex allergy. Which of the following client statements indicates a need for further teaching?
- A. I will apply elastic bandages to cuts.
- B. I will use dishwashing gloves when cleaning the dishes.
- C. I will use ink pens for writing.
- D. I will buy balloons for my son's birthday.
Correct Answer: D
Rationale: The correct answer is D. Latex allergy can be triggered by latex balloons. Therefore, buying balloons for the son's birthday could potentially expose the client to latex, leading to an allergic reaction. Elastic bandages, dishwashing gloves, and ink pens are typically latex-free alternatives. The other choices are incorrect because they do not involve direct exposure to latex.
A nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The available amount is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? How many clonidine tablets should the nurse administer?
Correct Answer: 3
Rationale: Correct Answer: 3
Rationale: To calculate the number of tablets needed, divide the total dose needed (0.3 mg) by the dose per tablet (0.1 mg). 0.3 mg ÷ 0.1 mg = 3 tablets. Therefore, the nurse should administer 3 tablets per dose.
Summary:
A: Incorrect - Not the correct number of tablets based on the dosage calculation.
B: Incorrect - Not the correct number of tablets based on the dosage calculation.
C: Incorrect - Not the correct number of tablets based on the dosage calculation.
D: Incorrect - Not the correct number of tablets based on the dosage calculation.
E: Incorrect - Not the correct number of tablets based on the dosage calculation.
F: Incorrect - Not the correct number of tablets based on the dosage calculation.
G: Incorrect - Not the correct number of tablets based on the dosage calculation.
A nurse is about to administer a daily dose of potassium chloride 20 mEq suspension orally. The available amount is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer? How many mL of potassium chloride should the nurse administer?
Correct Answer: 2
Rationale: To determine the amount of suspension needed, divide the desired dose (20 mEq) by the concentration (10 mEq/mL). 20 mEq ÷ 10 mEq/mL = 2 mL. This calculates the correct amount of 2 mL. Other choices are incorrect as they do not follow this calculation, leading to inaccurate dosing.