Nokea
After implementing nursing interventions for a client with anxiety, which expected outcome does the nurse evaluate?
- A. The client avoids all kinds of anxiety-provoking stimuli
- B. The client has no need for written instructions for follow-up care
- C. The client accurately repeats information about the drug therapy
- D. There are no consequences if anxiolytic drug is discontinued suddenly
Correct Answer: C
Rationale: Accurate understanding of drug therapy ensures compliance and safety, reducing the risk of adverse effects.
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What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.
What is first-line therapy for insomnia?
- A. Complementary therapies such as melatonin
- B. Cognitive-behavioral therapies such as relaxation therapy
- C. Benzodiazepine-receptor-like agents (e.g., zolpidem [Ambien])
- D. Over-the-counter medication such as diphenhydramine (Benadryl)
Correct Answer: B
Rationale: The correct answer is B. Cognitive-behavioral therapy (CBT) is the first-line treatment for insomnia due to its effectiveness and lack of side effects. Melatonin (A) and over-the-counter medications (D) are secondary options, while benzodiazepines (C) are reserved for short-term use.
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown:
- A. Ileostomy.
- B. Transverse colostomy.
- C. Ileal conduit.
- D. Sigmoid colostomy.
Correct Answer: A
Rationale: Ileostomies produce more caustic effluent, increasing skin irritation risk.
What should the nurse do if Wendy develops moderate hypotension and irregular pulse while receiving aminophylline?
- A. Check apical pulse and blood pressure every 10 minutes and continue present aminophylline administration
- B. Discontinue the aminophylline drip and call the physician
- C. Rapidly administer epinephrine 1:1000 intravenously
- D. Slow the rate of aminophylline administration, monitor vital signs, and notify physician
Correct Answer: D
Rationale: Adjusting the infusion rate prevents further adverse effects.
Yesterday, a male client had a transurethral resection of the prostate (TURP). Today, the client is concerned about the small amount of blood found in his urine. The nurse should explain to the client that the blood:
- A. should not be there on the second day.
- B. will stop when the Foley catheter is removed.
- C. is normal and he should not be concerned.
- D. can be removed by irrigating the bladder.
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. The client will continue to have a small amount of hematuria even after the Foley catheter is removed. Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. Irrigating the bladder will not remove the hematuria. Irrigation is performed to remove blood clots and to facilitate urinary drainage.