Nokea
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
- A. Determine whether the ear infection has affected her hearing.
- B. Determine whether she needs a tympanoplasty.
- C. Document that the infection has completely cleared.
- D. Obtain a new prescription in case the infection recurs.
Correct Answer: C
Rationale: A recheck confirms the otitis media has cleared, preventing complications. Hearing tests or tympanoplasty are not routine, and new prescriptions are unnecessary unless recurrence occurs.
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A 56-year-old woman is receiving digoxin (Lanoxin) 0.25 mg PO qd and furosemide (Lasix) 40 mg PO bid. She calls her physician for complaints of mild diarrhea. The physician prescribes Kaopectate 60 mg after each bowel movement for 2 days and instructs her to call back if symptoms don't subside.
The nurse should instruct the woman to
- A. make no changes in her medication schedule.
- B. wait 1 hour before taking her scheduled medications if she takes the Kaopectate.
- C. hold her scheduled medications until the diarrhea subsides.
- D. take the Lanoxin but hold the Lasix if she takes the Kaopectate.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) PO meds would be absorbed by Kaopectate not by stomach (2) correct-Kaopectate absorbs PO meds, separate administration of other meds (3) other meds should be given later (4) both meds should be given later
The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Weight gain of 1 kg since last dialysis
- C. Fistula site with a strong thrill
- D. Temperature of 100.8°F (38.2°C)
Correct Answer: D
Rationale: A temperature of 100.8°F suggests infection, a serious complication in hemodialysis patients due to their immunocompromised state and vascular access. Options A, B, and C are normal: BP is stable, 1 kg weight gain is expected fluid retention, and a strong thrill indicates a patent fistula.
The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
- A. The client should stay isolated from the rest of the family.
- B. No one who is pregnant should care for the client.
- C. The family should wash hands before and after caring for the client.
- D. The client should not be allowed to have any visitors.
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.
The nurse's aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck.
Which of the following observations, if made by the nurse, would require an intervention?
- A. The woman removes her dentures and gives them to her husband.
- B. The woman's vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
- C. The woman has a nitroglycerine patch on her right chest area.
- D. The woman has red nail polish on her fingers and toes.
Correct Answer: C
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) should be removed before the Test (2) results are within normal limits (3) correct-should be removed before the Test (4) unnecessary to check capillary refill
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).