Nokea
A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery. Which actions should the nurse include in the plan of care (select all that apply)?
- A. Label the catheter as an epidural access
- B. Assess the patient’s pain relief frequently
- C. Use sterile technique when caring for the catheter
- D. Monitor the patient’s level of consciousness (LOC)
Correct Answer: B
Rationale: The correct answers are B. All listed actions are essential for safe and effective care.
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What is the side effect caused by tyramine in foods when taking an MAOI inhibitor?
- A. Cardiac dysrrhythmias
- B. Thyroid storm
- C. Hypertensive crisis
- D. Rhabdomyolysis
Correct Answer: C
Rationale: Tyramine interacts with MAOIs to cause a dangerous rise in blood pressure, known as hypertensive crisis.
When caring for an older adult client with a pulmonary infection, what action should the nurse take first?
- A. Encourage the client to increase fluid intake.
- B. Assess the client's level of consciousness.
- C. Raise the head of the bed to at least 45 degrees.
- D. Provide the client with humidified oxygen.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's level of consciousness. This is the priority because changes in consciousness can indicate deteriorating respiratory status or potential respiratory distress. Next steps would depend on the assessment findings.
A: Encouraging fluid intake is important but not the first priority.
C: Raising the head of the bed helps with breathing but doesn't address potential immediate respiratory distress.
D: Providing humidified oxygen may be necessary but assessing consciousness comes first to determine the urgency of oxygen therapy.
What priority nursing action should you take?
- A. Notify the physician immediately
- B. Administer supplemental oxygen
- C. Have the student breathe into a paper bag
- D. Obtain an order for an anxiolytic medication
Correct Answer: C
Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.
What is a common cause of sensorineural hearing loss?
- A. Otitis media
- B. Temporal bone fractures
- C. Otitis externa
- D. Vascular conditions
Correct Answer: D
Rationale: Vascular conditions impair blood supply to the cochlea, causing sensorineural hearing loss.
What factor would be most important to include in Wendy’s discharge teaching plan?
- A. Effective breathing and coughing techniques
- B. Scheduling of return follow-up visits
- C. Program of recommended and contraindicated activities
- D. Individualized measures to prevent future attacks
Correct Answer: D
Rationale: Preventive measures reduce the likelihood of recurrent attacks.