Nokea
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim:
- A. Starts to become cyanotic.
- B. Cannot speak due to airway obstruction.
- C. Can make only minimal vocal noises.
- D. Is coughing vigorously.
Correct Answer: B
Rationale: Inability to speak indicates a complete airway obstruction, necessitating the Heimlich maneuver to dislodge the blockage.
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The nurse is monitoring a client who received ketamine for anesthesia induction. Which side effect should the nurse prioritize?
- A. Hypotension.
- B. Respiratory depression.
- C. Vivid dreams or hallucinations.
- D. Bradycardia.
Correct Answer: C
Rationale: Ketamine can cause vivid dreams or hallucinations, which may distress the client during recovery. Monitoring and reassuring the client are critical to manage this psychological side effect.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.
What is the purpose of sodium polystyrene sulfonate in acute renal failure?
- A. Lower blood pressure.
- B. Reduce serum potassium.
- C. Increase urine output.
- D. Correct acidosis.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate removes potassium from the body, treating hyperkalemia.
Before undergoing a transsphenoidal hypophysectomy, the client asks the nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the knowledge that:
- A. Dissolvable sutures are used to close the dura.
- B. Nasal packing provides pressure until normal wound healing occurs.
- C. A patch is made with a piece of fascia.
- D. A synthetic mesh is placed to facilitate healing.
Correct Answer: C
Rationale: A fascial patch is commonly used to repair the dura during transsphenoidal hypophysectomy to prevent CSF leaks.
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:
- A. Limited motion of joints.
- B. Deformed joints of the hands.
- C. Early morning stiffness.
- D. Rheumatoid nodules.
Correct Answer: C
Rationale: Early morning stiffness is a hallmark symptom of rheumatoid arthritis, especially in the early stages, as it reflects joint inflammation that worsens after periods of inactivity.