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An I.V. infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?
- A. It may be necessary to remove a small amount of hair from the infant's scalp.
- B. A sedative will be given to help keep the infant quiet.
- C. Administering the infant will be delayed until the infusion has been completed.
- D. Holding the infant will be contraindicated while the infusion is being administered.
Correct Answer: A
Rationale: Removing a small amount of hair may be necessary to secure the I.V. site on the scalp.
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A client who has had a laparoscopic cholecystectomy receives discharge instructions from the nurse. Which statement indicates that the client has understood the instructions?
- A. I need to maintain a low-fat diet for the next 6 months
- B. I can remove the dressing from my incision tomorrow and take a shower
- C. I can anticipate some nausea for several days after surgery
- D. I can return to work in 4 to 6 weeks
Correct Answer: B
Rationale: Removing the dressing and showering the day after a laparoscopic cholecystectomy is standard, as incisions are small. A low-fat diet may be advised but not for a fixed 6 months, nausea is not expected, and return to work is typically sooner.
The nurse is counseling a client about the prevention of coronary heart disease. Which of the following vitamins should the nurse recommend the client include in his diet to reduce homocysteine levels? Select all that apply.
- A. Vitamin K.
- B. Vitamin B6.
- C. Folate.
- D. Vitamin B12.
- E. Vitamin D.
Correct Answer: B, C, D
Rationale: Vitamin B6, folate, and vitamin B12 reduce homocysteine levels, a risk factor for coronary heart disease.
A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item should the nurse caring for the client immediately obtain?
- A. A pacemaker
- B. A defibrillator
- C. A second dose of lidocaine
- D. An electrocardiogram machine
Correct Answer: B
Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.
The nurse is assessing a client with a suspected acute pancreatitis. Which of the following laboratory findings is most indicative of this condition?
- A. Elevated amylase and lipase.
- B. Decreased white blood cell count.
- C. Elevated hemoglobin.
- D. Decreased blood glucose.
Correct Answer: A
Rationale: Elevated amylase and lipase are hallmark laboratory findings in acute pancreatitis due to pancreatic enzyme release.
A client with a history of type 1 diabetes is admitted with hyperglycemia. The nurse should include which of the following in the plan of care?
- A. Administer regular insulin as prescribed.
- B. Restrict fluid intake.
- C. Encourage a high-carbohydrate diet.
- D. Administer glucagon.
Correct Answer: A
Rationale: Regular insulin corrects hyperglycemia in type 1 diabetes.