Nokea
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
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A client has severe second- and third-degree burns over 75% of his body.
The nurse would be MOST concerned if which of the following was observed?
- A. Epigastric pain.
- B. Restlessness.
- C. Tachypnea.
- D. Lethargy.
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain
A nine-month-old child with complaints of a fever of 102.2°F (39°C) and frequent vomiting.
The nurse would expect which of the following reflexes to still be present?
- A. Babinski's reflex.
- B. Moro's reflex.
- C. Tonic neck reflex.
- D. Grasp reflex.
Correct Answer: A
Rationale: Strategy: Think about growth and development. (1) correct-stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex, disappears after one year of age (2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape, disappears after 3-4 months (3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex, disappears by age 3-4 months (4) touching palms of hands or soles of feet causes flexion of hands and toes, palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of age
A client develops severe, crushing chest pain radiating to the left shoulder and arm.
Which of the following PRN medications should the nurse administer?
- A. Diazepam (Valium) PO.
- B. Meperidine (Demerol) IM.
- C. Morphine sulfate IV.
- D. Nitroglycerine (Nitrostat) SL.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not an appropriate medication in this situation; antianxiety medication (2) Demerol is less commonly used because it may induce vomiting and initiate a vagal response (3) correct-morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload pressures (4) although a client at home may have taken NTG SL, the nurse would administer it IV to reduce pain and decrease overload
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission?
- A. A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago
- B. A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24 hours ago
- C. An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning
- D. An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago
Correct Answer: A
Rationale: The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client in option A is most likely stable and could continue medication therapy at home.
Which statement made by an adolescent indicates understanding of how to reduce risk of osteoporosis later in life?
- A. I will be careful not to sprain my ankle when I play sports.'
- B. I drink a glass of milk with every meal.'
- C. As I get older, I will reduce the amount of weight-bearing exercise I do.'
- D. My favorite beverages are cola drinks.'
Correct Answer: B
Rationale: High calcium intake (milk) builds bone density, reducing osteoporosis risk. Sprains, reduced exercise, or cola drinks don't address bone health.