Nokea
After a cardiac catheterization procedure, the nurse should ask the client to remain in which position?
- A. on the left side, with both knees bent slightly
- B. semi-Fowler's position
- C. supine with a small pillow under the head
- D. high-Fowler's position
Correct Answer: C
Rationale: The supine position with a small pillow under the head promotes comfort and prevents bleeding from the catheter insertion site (usually femoral) after cardiac catheterization.
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Which would be included in the nursing care plan of a client experiencing severe delirium tremens?
- A. Placing the client in a darkened room
- B. Keeping the closet and bathroom doors closed
- C. Administering a diuretic to decrease fluid excess
- D. Checking vital signs every 8 hours
Correct Answer: B
Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.
A 9-year-old child weighing 40 kilograms has an order for piperacillin (Pipracil) via IV infusion. The recommended daily dose for this medication is 240-300 mg/kg/day IV div. q8h. What is the maximum daily dose of piperacillin this client can receive per day? Calculate and fill in the blank.
Correct Answer: 12,000 mg
Rationale: Maximum dose: 300 mg/kg/day × 40 kg = 12,000 mg/day.
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about:
- A. Bleeding precautions
- B. Prevention of falls
- C. Oxygen therapy
- D. Conservation of energy
Correct Answer: A
Rationale: With a platelet count of 80,000, the client is at risk for bleeding, so teaching bleeding precautions is critical to prevent complications.
A med-surg nurse is floating to the post-op floor for a few days. The float nurse sees one of the regular post-op nurses taking medication from the med cart and ingesting several pills. The float nurse should immediately
- A. inform the state board of nursing.
- B. inform the nursing supervisor who works on the post-op floor.
- C. report the nurse to human resources.
- D. confront the post-op nurse about stealing and abusing medications.
Correct Answer: B
Rationale: Reporting to the nursing supervisor ensures prompt investigation and intervention for suspected medication diversion, maintaining patient safety.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- A. Her contractions are 2 minutes apart.
- B. She has back pain and a bloody discharge.
- C. She experiences abdominal pain and frequent urination.
- D. Her contractions are 5 minutes apart.
Correct Answer: D
Rationale: Contractions 5 minutes apart indicate the onset of active labor, prompting further evaluation.