Nokea
A serious complication of a total hip replacement is displacement of the prosthesis. What is the primary sign of displacement?
- A. pain on movement and weight bearing
- B. hemorrhage
- C. affected leg appearing 1-2 inches longer
- D. edema in the area of the incision
Correct Answer: A
Rationale: Pain on movement and weight bearing indicates pressure on the nerves or muscles caused by the dislocation. Other symptoms of dislocation include an inability to bear weight and a shortening of the affected leg. Edema is not a primary sign of displacement.
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The nurse is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. I am nervous about how painful labor will be.
- B. I need to review my finances and make sure I am prepared to care for a child.
- C. I hate this nausea that I've been having for a week.
- D. I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent.
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea.
The nurse is caring for the client taking atorvastatin. The nurse should assess for which adverse effects?
- A. Constipation and hemorrhoids
- B. Muscle pain and weakness
- C. Fatigue and dysrhythmias
- D. Flushing and postural hypotension
Correct Answer: B
Rationale: A: Bile acid sequestrants act by inhibiting bile acids from absorption by the small intestine. This results in fewer bile acids in the small intestine, which may lead to constipation and hemorrhoids. B: Atorvastatin (Lipitor) is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) used to lower lipid levels. Statins can cause muscle tissue injury manifested by muscle ache or weakness. Muscle injury can progress to myositis (muscle inflammation) or rhabdomyolysis (muscle disintegration). C: Diarrhea, not constipation, has been found to be a side effect of statin medications. D: Side effects of niacin, a lipid-lowering agent, include flushing, dysrhythmias, and postural hypotension.
The nurse is storing vaccines for future use. What should the nurse do so they are properly stored? Select all that apply.
- A. Place all vaccines in a temperature-controlled refrigerator.
- B. Complete periodic checks of the expiration date on the vaccines.
- C. Place bulk supplies of vaccines in a temperature-controlled freezer.
- D. Avoid storing vaccines on the shelf in the door of the refrigerator.
- E. Do not store food or beverage in the same refrigerator or freezer as the vaccines.
Correct Answer: B,D,E,F
Rationale: A: Not all vaccines are refrigerated; some vaccines will be inactivated by refrigeration and freezing. B: Periodic checking for expiration dates is necessary to ensure that outdated vaccines are not administered. C: Not all bulk supplies should be placed in a freezer; some vaccines are inactivated by freezing. D: When refrigeration is required, a main shelf inside the refrigerator is best because a shelf in the door will have frequent temperature changes that will alter the potency of the vaccine. E: Storing food and beverage in the same unit may result in frequent opening of the unit, leading to greater chance of temperature instability and light exposure. Contamination may also result. F: Aluminum foil or packaging can be used to protect light-sensitive vaccines.
The client has a new prescription for metoclopramide. The nurse notifies the HCP because the client has a contraindication for metoclopramide use. Which information in the client's medical record most likely prompted the nurse's notification of the HCP?
- A. Use of nasogastric suctioning
- B. History of diabetes mellitus
- C. History of seizure disorders
- D. Chemotherapy treatment for cancer
Correct Answer: C
Rationale: A: The use of NG suctioning alone would not prevent metoclopramide use. Metoclopramide can be administered through the NG tube; the tube is then clamped for an hour after administration until absorption occurs. B: Metoclopramide should be used with caution with DM, but it is not contraindicated. C: The client's history of a seizure disorder would contraindicate the use of metoclopramide. Because metoclopramide (Reglan) blocks dopamine receptors in the chemoreceptor trigger zone of the CNS, it is contraindicated in seizure disorders. D: Metoclopramide is used in the treatment of nausea and vomiting for clients receiving chemotherapy.
The nurse is preparing to administer the client's medication for treatment of TB. Which medication, if on the client's MAR, should the nurse plan to administer?
- A. Isoniazid
- B. Fluconazole
- C. Azithromycin
- D. Acyclovir
Correct Answer: A
Rationale: A: Isoniazid (INH) is an antimycobacterial medication affecting bacterial cell wall synthesis; it is used in the treatment of TB or other mycobacterial infections. B: Fluconazole (Diflucan) is an antifungal agent that inhibits synthesis of fungal sterols, a necessary component of the cell membrane. C: Azithromycin (Zithromax) is a macrolide antibiotic that is bacteriostatic against susceptible bacteria and is usually used for treating lower respiratory tract infections, skin infections, acute otitis media, tonsillitis, or Mycobacterium avium. D: Acyclovir (Zovirax) is an antiviral agent limited to treatment of herpes viruses.