Nokea
After administering injections of penicillin, the nurse should ask the client to wait at least __ minutes before allowing the client to leave the healthcare facility.
- A. 12
- B. 15
- C. 5
- D. 30
Correct Answer: B
Rationale: The rationale is that waiting 15 minutes allows time to observe for any adverse reactions to the medication.
You may also like to solve these questions
Which type of agent does sulfur mustard fall under?
- A. Nerve agents
- B. Blistering agents
- C. Respiratory toxins
- D. Cyanide poisonings
Correct Answer: B
Rationale: The correct answer is B because sulfur mustard is a blistering agent that causes skin and respiratory damage.
What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.
A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Continue to monitor the client as this is an expected finding.
- B. Add more water to the suction control chamber of the drainage system.
- C. Verify that the suction regulator is on and check the tubing for leaks.
- D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Correct Answer: C
Rationale: The correct answer is C: Verify that the suction regulator is on and check the tubing for leaks.
Rationale:
1. Lack of bubbling in the suction control chamber indicates suction may not be working.
2. Checking the suction regulator ensures it is on and at the correct level for proper drainage.
3. Checking tubing for leaks ensures the system is intact and functioning properly.
4. This intervention addresses the potential issue of inadequate suction, which can affect the client's postoperative recovery.
Summary:
- Option A: Continuing to monitor is not appropriate as lack of bubbling suggests an issue with suction.
- Option B: Adding more water to the suction control chamber is unnecessary and does not address the root cause.
- Option D: Milking the chest tube is not recommended as it can cause trauma and dislodging clots may lead to complications.
When developing a teaching plan for a patient, what should the nurse recognize?
- A. Frustration will enhance the patient’s desire to learn
- B. Only formal teaching plans have been found to be effective
- C. The patient’s previous educational experiences do not influence his learning
- D. The patient must accept responsibility for compliance with his therapeutic regimen
Correct Answer: D
Rationale: Patient responsibility is essential for adherence to therapeutic regimens.
A male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:
- A. continue to monitor the foot.
- B. immediately notify the physician.
- C. notify the head nurse.
- D. assure the client that his foot is fine.
Correct Answer: B
Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.