Nokea
A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment?
- A. Pulse
- B. Respirations
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: In an emergency situation, the nurse should determine breathlessness first and then assess for a pulse. Blood pressure would be assessed after these assessments are performed. Urinary output is also important but is not the priority at this time.
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A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action?
- A. Monitor the fetal heart rate.
- B. Notify the primary health care provider.
- C. Transfer the client to the delivery room.
- D. Place the client in the Trendelenburg position.
Correct Answer: D
Rationale: On inspection of the perineum, if the umbilical cord is noted, the nurse immediately places the client in the Trendelenburg position while gently holding the presenting part upward to relieve the cord compression. This position is maintained and the primary health care provider is notified. The fetal heart rate also needs to be monitored to assess for fetal distress. The client is transferred to the delivery room when prescribed by the primary health care provider.
The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip. What is the initial action to be taken by the nurse?
- A. Notify the primary health care provider.
- B. Initiate cardiopulmonary resuscitation (CPR).
- C. Continue to monitor the client and the heart rate patterns.
- D. Administer oxygen with a face mask at 8 to 10 L per minute.
Correct Answer: B
Rationale: The monitor is showing ventricular fibrillation, a life-threatening dysrhythmia that requires CPR and defibrillation to maintain life. Although the primary health care provider must be notified, CPR is the initial action. Oxygen is necessary, but again the initiation of CPR is the priority because it will provide more than just oxygen to the client. Monitoring the client is necessary, but not as an initial action; emergency resuscitative treatment must be provided to the client immediately.
What action should the nurse take to assess the pharyngeal reflex on a child?
- A. Ask the client to swallow.
- B. Pull down on the lower eyelid.
- C. Shine a light toward the bridge of the nose.
- D. Stimulate the back of the throat with a tongue depressor.
Correct Answer: D
Rationale: The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. Asking the client to swallow assesses the swallowing reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas).
The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube. The nurse should place the client in which position to administer the feeding?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Lateral recumbent
Correct Answer: B
Rationale: Clients are at high risk for aspiration during an NG tube feeding because the tube bypasses a protective mechanism, the gag reflex. The head of the bed is elevated 35 to 40 degrees (Semi-Fowler's) to prevent this complication by facilitating gastric emptying. The remaining options increase the risk of aspiration by blunting the effect of gravity on gastric emptying.
A client is receiving cisplatin. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
- A. Tinnitus
- B. Increased appetite
- C. Excessive urination
- D. Yellow halos in front of the eyes
Correct Answer: A
Rationale: Cisplatin is an antineoplastic medication. An adverse effect related to the administration of cisplatin is ototoxicity with hearing loss. The nurse should assess for this adverse reaction when administering this medication. Options 2, 3, and 4 are not adverse effects of this medication.