Nokea
At a 6-month-old infant is being admitted from the emergency department with dehydration secondary to viral gastroenteritis. Which of the following room assignments is the most appropriate for this infant?
- A. A semiprivate room with an 8-year-old child who has had an appendectomy.
- B. A semiprivate room with a 10-year-old child with a dressed head injury.
- C. A private room.
- D. A semiprivate room with a 4-year-old child with leukemia.
Correct Answer: C
Rationale: Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room to prevent the spread of infection.
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Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication?
- A. Nausea
- B. Hypotension
- C. Blurred vision
- D. Excessive drooling
Correct Answer: D
Rationale: Adverse effects of antipsychotic medications such as haloperidol include marked drowsiness and lethargy; extrapyramidal symptoms, including parkinsonism effects (drooling); dystonias; akathisia; and tardive dyskinesia. The correct option is a parkinsonism effect of this medication, excessive drooling. Nausea, hypotension, and blurred vision are occasional side effects of the medication.
A client with a history of breast cancer is admitted with bone metastases. The nurse should include which of the following in the plan of care?
- A. Administer bisphosphonates as prescribed.
- B. Restrict calcium intake.
- C. Encourage bed rest.
- D. Apply cold packs to affected areas.
Correct Answer: A
Rationale: Bisphosphonates reduce bone resorption and pain in bone metastases.
The charge nurse on the postpartum unit has received report about a client with a fetal demise who has just delivered and will be ready for transfer out of Labor and Delivery in about 2 hours. The client has asked her primary nurse if she can stay on the unit since she found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?
- A. Request a room for this client on a unit without newborns.
- B. Ask the nurse in labor and delivery to discharge the mother as soon as she is physically able to leave.
- C. Talk to the mother first and decide on a location that is mutually agreeable.
- D. Admit the mother to a private room on the postpartum unit.
Correct Answer: A
Rationale: Placing the client on a unit without newborns minimizes emotional distress from being near other newborns after a fetal demise.
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
- A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
- B. You will need the help of another nurse prior to the administration of these packed red blood cells.
- C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
- D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Correct Answer: D
Rationale: Monitoring the client for at least 15-30 minutes after starting a transfusion is critical to detect acute reactions like hemolysis or allergic responses.
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms?
- A. Sore throat and muscle aches.
- B. Nausea and flushing of the face and neck.
- C. Fever and muscle soreness.
- D. Bradycardia and vertigo.
Correct Answer: B
Rationale: Disulfiram causes an adverse reaction with alcohol, leading to symptoms like nausea and flushing due to acetaldehyde accumulation.