Nokea
A patient has a Levin tube connected to intermittent low suction. At 7 AM, the nurse charts that there is 235 cc of greenish drainage in the suction container. At 3 PM, the nurse notes that there is 445 cc of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?
- A. 150 cc.
- B. 210 cc.
- C. 295 cc.
- D. 385 cc.
Correct Answer: A
Rationale: 445-235=210-60=150
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Several days after a client had a myocardial infarction, the physician placed him on a 2-gm sodium diet.
Which of the following selections would indicate to the nurse an understanding of the diet?
- A. Scrambled egg, orange slices, and milk.
- B. Instant oatmeal, toast, and orange juice.
- C. Poached egg, bacon, and milk.
- D. Biscuit, fruit cup, and sausage.
Correct Answer: A
Rationale: Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct-all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all baked breads are high in sodium, as is sausage
The nurse is caring for a manic client in the seclusion room, and it is time for lunch.
- A. What is the most appropriate action for the nurse to take for a manic client in the seclusion room at lunchtime?
- B. Take the client to the dining room with 1:1 supervision.
- C. Inform the client he may go to the dining room when he controls his behavior.
- D. Hold the meal until the client is able to come out of seclusion.
- E. Serve the meal to the client in the seclusion room.
Correct Answer: D
Rationale: For safety, a manic client in seclusion should remain in the seclusion room and have meals served there to maintain a controlled environment. Taking the client to the dining room risks escalation, delaying the meal is unnecessary, and linking meals to behavior control is inappropriate.
A 60-year-old man with a diagnosis of pneumonia.
The nurse should place the patient in a room with which of the following patients?
- A. A 20-year-old in traction for multiple fractures of the left lower leg.
- B. A 35-year-old with recurrent fever of unknown origin.
- C. A 50-year-old recovering alcoholic with cellulitis of the right foot.
- D. An 89-year-old with Alzheimer's disease awaiting nursing home placement.
Correct Answer: C
Rationale: Strategy: Determine the transmission of organisms. (1) patient with fractures are considered 'clean,' don't place with an infectious patient (2) don't know the cause of the fever (3) correct-generalized nonfollicular infection that involves deeper connective tissue, both patients have infections (4) elderly are high risk for developing pneumonia
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
The nurse is assessing cranial nerve XI. The nurse should:
- A. open a vial of cloves and ask the client to identify the scent.
- B. shine a flashlight in the client's eyes and observe the pupils.
- C. ask the client to shrug his shoulders.
- D. use the Snellen chart and have the client identify letters.
Correct Answer: C
Rationale: Cranial nerve XI (spinal accessory) controls neck and shoulder muscles; shoulder shrugging tests its function, unlike scent (I), pupil response (III), or vision (II).