Nokea
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
- A. Administer oxygen via nasal cannula
- B. Have narcan (naloxane) available
- C. Prepare to administer blood products
- D. Prepare to do cardioresuscitation
Correct Answer: B
Rationale: Narcan reverses opioid overdose, a potential complication of narcotic use post-surgery.
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The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?
- A. Adding fresh ground pepper to my food will improve the flavor.
- B. Meat should be thoroughly cooked to the proper temperature.
- C. Eating cheese and yogurt will prevent AIDS-related diarrhea.
- D. It is important to eat four to five servings of fresh fruits and vegetables a day.
Correct Answer: B
Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their weakened immune systems.
The nurse is caring for a client with dementia who tends to wander. Which of the following actions can help with this behavior? Select all that apply.
- A. providing frequent toileting or incontinence care as needed
- B. assessing client for pain and treat with appropriate medications
- C. reorienting the client and use validation therapy, as appropriate
- D. allowing the client to sit in a recliner at the nurses' station for close monitoring
- E. using chemical or physical restraints to prevent the client from exiting the bed
Correct Answer: A, B, C, D
Rationale: Frequent toileting, pain management, reorientation, and close monitoring address wandering causes and promote safety. Restraints are a last resort and not ideal for wandering.
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. She is very irritable lately.
- B. She sleeps quite a bit of the time.
- C. Her gums look too big for her teeth.
- D. She has gained about 10 pounds in the last six months.
Correct Answer: C
Rationale: Gingival hyperplasia is a common side effect of phenytoin therapy.
The nurse answers a call to the unit, which turns out to be a bomb threat. Which actions by the nurse are correct? Select all that apply.
- A. dismiss the call as a prank
- B. follow facility protocol to ensure client and staff safety
- C. try to find out where the bomb is and when it will go off
- D. alert the charge nurse, security, and the police department
- E. start evacuating clients, starting with those who are most mobile first
Correct Answer: B, D
Rationale: Following protocol and alerting authorities ensure safety and proper response, while dismissing the threat or evacuating without orders is unsafe.
Which laboratory finding would indicate a 62-year-old male client is at risk for ventricular dysrhythmia?
- A. magnesium 0.8 mmEq/L
- B. potassium 4.2 mmol/L
- C. creatinine 1.3 mg/dL
- D. total calcium 2.8 mmol/L
Correct Answer: A
Rationale: Low magnesium (0.8 mEq/L; normal 1.5-2.5 mEq/L) increases the risk of ventricular dysrhythmias. Other values are within normal ranges.