Nokea
A young adult is admitted with a diagnosis of Guillain-Barré syndrome. Which nursing action will be of highest priority as the nurse plans care?
- A. Range-of-motion exercises
- B. Monitor respirations
- C. Turn every two hours
- D. Provide emotional support
Correct Answer: B
Rationale: Guillain-Barré syndrome can cause ascending paralysis, risking respiratory muscle weakness; monitoring respirations is critical to detect respiratory failure early.
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The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse would be to inform them that
- A. Circumcision is delayed so the foreskin can be used for the surgical repair
- B. This procedure is contraindicated because of the permanent defect
- C. There is no medical indication for performing a circumcision on any child
- D. The procedure should be performed as soon as the infant is stable
Correct Answer: A
Rationale: Circumcision is delayed so the foreskin can be used for the surgical repair. Even if only mild hypospadias is suspected, circumcision is not done to save the foreskin for surgical repair.
A client receiving amphotericin B (Fungizone) 1 mg in 250 cc of 5% dextrose in water IV over a 2-hour period.
The nurse should be MOST concerned if which of the following was observed?
- A. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
- B. BP 90/60, complaints of fever and chills.
- C. Complaints of burning on urination, thirst, and dizziness.
- D. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin 0.2 mg/dL.
Correct Answer: B
Rationale: Strategy: 'MOST concerned' indicates an untoward effect of the medication. (1) normal results, causes renal toxicity, BUN and creatine would be elevated, normal BUN 7-18 mg/dL, normal creatine 0.6-1.2 mg/dL (2) correct-monitor vital signs every 30 min (3) not side effect of medication (4) normal AST (formerly SGOT) 8-20 U/L, normal ALT (formerly SGPT) 8-20 U/L, normal bilirubin 0.1-1.0 mg/dL, may cause elevation, check liver function studies weekly, notify physician if elevated
A withdrawn, depressed client sits in the day room but refuses to participate in scheduled group activities. When implementing a plan of care the nurse should:
- A. Plan activity that will allow the client to interact with a staff member.
- B. Tell the client that participation in group activities is expected.
- C. Allow the client to select an activity that he can enjoy doing alone.
- D. Ask the client to prepare a list of activities or hobbies he enjoys.
Correct Answer: A
Rationale: One-on-one interaction with a staff member encourages engagement without overwhelming a depressed client. Mandating participation may increase withdrawal. Solitary activities (C, D) do not address social isolation.
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
- A. Remove the unsightly markings with acetone or alcohol.
- B. Cover the radiation site with loose gauze dressing.
- C. Sprinkle baby powder over the radiated area.
- D. Refrain from using soap or lotion on the marked area.
Correct Answer: D
Rationale: Refraining from using soap or lotion preserves radiation site markings, ensuring accurate treatment. Removing markings, covering, or using powder risks disrupting the treatment field.
When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST?
- A. After pursed-lip breathing, cough into a container.
- B. Upon awakening, cough deeply and expectorate into a container.
- C. Save all sputum for three days in a covered container.
- D. After respiratory treatment, expectorate into a container.
Correct Answer: B
Rationale: specimens should be obtained in the early morning because secretions develop during the night