Nokea
An elderly adult is scheduled for repair of a fractured femur this morning. The nurse goes in to administer the preoperative medication of Demerol 75 mg and atropine 0.4 mg IM. The client asks the nurse if he should take his eye drops before surgery. What is the best initial response for the nurse to make?
- A. You can take them when you get back from surgery.
- B. I'll give them to you now.
- C. Let me check with your physician.
- D. What kind of eye drops are you taking?
Correct Answer: D
Rationale: Knowing the type of eye drops (e.g., for glaucoma or infection) determines if they are critical pre-surgery, guiding further action.
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The client is receiving a loop diuretic for congestive heart failure. Which medication would the nurse expect the client to be receiving while taking this medication?
- A. A potassium supplement.
- B. A cardiac glycoside.
- C. An ACE inhibitor.
- D. A potassium cation.
Correct Answer: A
Rationale: Loop diuretics like furosemide cause potassium loss; supplements prevent hypokalemia, a common need in CHF.
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.
The nurse is assessing a client who is on long term glucocorticoid therapy. Which of the following findings would the nurse expect?
- A. Buffalo hump
- B. Increased muscle mass
- C. Peripheral edema
- D. Jaundice
Correct Answer: A
Rationale: Buffalo hump. With high doses of glucocorticoid, iatrogenic Cushing's syndrome develops. The exaggerated physiological action causes abnormal fat distribution which results in a moon-shaped face, an intrascapular pad on the neck (buffalo hump) and truncal obesity with slender limbs.
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
A client in respiratory distress is admitted with arterial blood gas results of PH 7.30, PO2 58, PCO2 34, and HCO3 19. The nurse determines that the client is in
- A. metabolic acidosis
- B. metabolic alkalosis
- C. respiratory acidosis
- D. respiratory alkalosis
Correct Answer: A
Rationale: metabolic acidosis. These lab values indicate metabolic acidosis: the PH is low, PCO2 is normal, and bicarbonate level is low.