Nokea
A nurse is teaching a camp counselor about the treatment of snake bites to an extremity. Which of the following information should be included in the teaching?
- A. apply a tourniquet above the affected site
- B. keep the extremity elevated above the heart
- C. if possible, try to capture the snake for easy identification
- D. do not apply ice to the affected site
Correct Answer: D
Rationale: Applying ice can cause tissue damage and is not recommended. Tourniquets (A) can worsen outcomes, elevation above the heart (B) is controversial and not universally advised, and capturing the snake (C) is unsafe and unnecessary with modern antivenom protocols.
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A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so hyperkalemia (B) is a key adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not typical.
What is the main reason desflurane (Suprane) and sevoflurane (Ultane), volatile liquid anesthesia agents, are used for surgical clients who go home the day of surgery?
- A. These agents are better tolerated.
- B. These agents are predictable in their cardiovascular effects.
- C. These agents are nonirritating to the respiratory tract.
- D. These agents are rapidly eliminated.
Correct Answer: D
Rationale: Desflurane and sevoflurane are rapidly eliminated, allowing quicker recovery and discharge, which is ideal for same-day surgery patients.
The nurse explains to the client with pain that the purpose of biofeedback is to enable him to exert control over his physiologic processes by:
- A. Regulating the body processes through electrical control.
- B. Shocking himself when an undesirable response is elicited.
- C. Monitoring the body processes for the therapist to interpret.
- D. Translating the signals of his body processes into observable forms.
Correct Answer: D
Rationale: Biofeedback translates physiological signals (e.g., heart rate) into observable forms, allowing the client to control them consciously. It does not involve electrical shocks, therapist interpretation, or direct electrical regulation.
When the nurse enters the client's room, the nurse perceives that the client is staring straight ahead. Which of the following is the best course of action for the nurse to take next?
- A. Hold an interdisciplinary meeting on the client's behalf promptly.
- B. Consult with psychiatry.
- C. Listen to the client and observe the body language.
- D. Address the client by first name upon entering the room.
Correct Answer: C
Rationale: Listening to the client and observing body language allows the nurse to assess the client's condition and needs, considering macular degeneration may cause the client to appear to stare straight ahead due to central vision loss.
A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high uric acid levels. Which of the following indicate the client is experiencing adverse effect(s) of this drug? Select all that apply.
- A. Nausea.
- B. Rash.
- C. Constipation.
- D. Flushed skin.
- E. Bone marrow depression.
Correct Answer: A,B,E
Rationale: Nausea, rash, and bone marrow depression are known adverse effects of allopurinol, indicating potential toxicity or allergic reactions.