Nokea
An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?
- A. Add a thickening agent to the fluids
- B. Check the client's gag reflex
- C. Feed the client only solid foods
- D. Increase the rate of intravenous fluids
Correct Answer: B
Rationale: Check the client's gag reflex. When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.
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The nurse is to administer cefazolin sodium 1 g in 100 mL 0.9% NaCl over 30 minutes. At what rate in mL/hour should the nurse plan to set the infusion pump?
Correct Answer: 200
Rationale: 100 mL/ 0.5 hours = 200 mL/hour.
A college student is hospitalized with meningococcal meningitis after being seen in the campus clinic. What is the nurse's responsibility to the campus community regarding this diagnosis?
- A. Quarantine all students and faculty remaining on the campus
- B. E-mail school administrators with the names of infected students
- C. Identify all individuals who have had close contact with the student
- D. Ensure that everyone on campus receive prophylactic antibiotics
Correct Answer: C
Rationale: C: Identifying close contacts allows targeted prophylaxis, preventing spread. A: Quarantine is excessive. B: Sharing names violates privacy. D: Prophylaxis is only for close contacts.
Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider?
- A. I started my period and now my urine has turned bright red'
- B. I am a diabetic and today I have been going to the bathroom every hour'
- C. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom'
- D. I went to the bathroom and my urine looked very red and it didn't hurt when I went'
Correct Answer: D
Rationale: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone.
Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?
- A. Eat a light diet for the rest of the day
- B. Rest for the next 24 hours since the preparation and the test is tiring
- C. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
- D. Measure the urine output for the next day and immediately notify the health care provider if it should decrease
Correct Answer: D
Rationale: This information would alert to the complication of acute renal failure which may occur as a complication from the dye and the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye injection.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.