Nokea
An elderly client with glaucoma is scheduled for an exploratory laparotomy. Which of the following pre-op medications should be questioned?
- A. Demerol (meperidine)
- B. Atropine (atropine)
- C. Tagamet (cimetadine)
- D. Polycillin (ampicillin)
Correct Answer: B
Rationale: Atropine is contraindicated in glaucoma as it can increase intraocular pressure. Demerol , Tagamet , and Polycillin are generally safe in this context.
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An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?
- A. Shellfish
- B. Molds
- C. Balloons
- D. Perfumed soap
Correct Answer: C
Rationale: Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
The nurse answers the psychiatric unit's desk phone. The caller identifies himself as the husband of a patient and inquires about her condition.
Which of the following responses by the nurse is MOST appropriate?
- A. I may not deny or confirm any patient's presence in this hospital.'
- B. Patients are not allowed to use this phone. Please call the patient's phone number directly.'
- C. I cannot give information over the phone. If you come in we can discuss her condition.'
- D. I will have to ask her if she wishes for me to give out that information.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) confidentiality prohibits a professional from discussing information about the patient (2) correct-psychiatric patient retains civil rights to communicate with outside world and have reasonable access to telephones (3) breaks confidentiality (4) patient able to speak for herself
The nurse is caring for an older adult. Which statement made by the client is not typical of normal aging?
- A. I seem to be more sensitive to the taste of salt than I used to be.'
- B. I have trouble reading the newspaper.'
- C. I don't drive at dusk anymore.'
- D. Sometimes I have trouble matching my socks.'
Correct Answer: A
Rationale: Increased sensitivity to salt taste is not typical of aging; taste sensitivity usually decreases. Difficulty reading, avoiding dusk driving, and color matching issues are normal aging changes.
A client on chemotherapy has a WBC count of 1,200/mm^3. Which of the following nursing actions should the nurse take FIRST?
- A. Check temperature q 4 h.
- B. Monitor urine output.
- C. Assess for bleeding gums.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: A WBC count of 1,200/mm^3 indicates severe neutropenia, increasing infection risk. Checking temperature every 4 hours detects fever early, a priority. Options B, C, and D are secondary: urine output is unrelated, bleeding gums suggest thrombocytopenia, and blood cultures require fever.
A fifty-five year-old man suffered a left frontal lobe CVA. The patient's family is not present in the room. Which of the following should the nurse watch most closely for?
- A. Changes in emotion and behavior
- B. Monitor loss of hearing
- C. Observe appetite and vision deficits
- D. Changes in facial muscle control
Correct Answer: A
Rationale: The frontal lobe is responsible for behavior and emotions.