Nokea
A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?
- A. Surgical gloves
- B. Luer lok fitting IV tubing
- C. Surgical hat cover
- D. Disposable long-sleeve gown
Correct Answer: C
Rationale: Surgical gloves, Luer lok tubing, and long-sleeve gowns are essential for safe chemotherapy administration to prevent exposure. A surgical hat cover (C) is not typically required unless in a sterile procedure.
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A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Allows the physician to visualize the subclavian vein
- B. Reduces the possibility of air embolism
- C. Reduces the possibility of hematoma formation
- D. Makes the procedure more comfortable for the client
Correct Answer: B
Rationale: The Trendelenburg position reduces air embolism risk by increasing central venous pressure and distending veins for easier catheter insertion.
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin reduces platelet aggregation, preventing clot formation in transient ischemic attacks, reducing stroke risk. It does not prevent headaches, boost coagulation, or directly prevent anoxia.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When assessing the client’s response to the Pitocin, the nurse should give priority to:
- A. Monitoring the blood pressure
- B. Checking the fetal heart rate
- C. Timing the frequency of contractions
- D. Assessing the urinary output
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, risking fetal distress. Checking the fetal heart rate is the priority to ensure fetal well-being. Blood pressure, contractions, and urinary output are monitored but are secondary to fetal status.
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
- A. Taping a pouch that is leaking
- B. Cutting the skin barrier 1 1/2 inches larger than the stoma
- C. Changing the pouch only when leakage occurs
- D. Using a skin sealant under pouch adhesives
Correct Answer: D
Rationale: When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.