Nokea
The nurse is preparing to begin a dopamine (Intropin) infusion on a client.
Before beginning the infusion the nurse should
- A. evaluate the urine output.
- B. obtain the client's weight.
- C. determine the patency of the IV line.
- D. measure pulmonary artery pressures.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to dopamine. (1) not a critical assessment at this time (2) contains correct information, but is not a priority (3) correct-if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects (4) not a critical assessment at this time
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A client with pharyngitis.
The clinic nurse is obtaining a throat culture from a client with pharyngitis. It is MOST important for the nurse to do which of the following?
- A. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
- B. Obtain a sputum container for the client to use.
- C. Irrigate with warm saline, and then swab the pharynx.
- D. Hyperextend the client's head and neck for the procedure.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tonsillar and pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended
A 20-year-old primipara attends a class for women who plan to breastfeed. To prepare for breastfeeding, the nurse should encourage the women to
- A. apply moisturizer to their breasts every day after bathing.
- B. expose their breasts to air every day for 20 minutes.
- C. wash their breasts with water and rub with a towel every day.
- D. massage their breasts to increase circulation twice daily.
Correct Answer: C
Rationale: prepares nipples for stretching action of sucking during breastfeeding, soap avoided to prevent drying
The nurse is caring for a client who is postoperative day 1 after a total abdominal hysterectomy. Which of the following findings should the nurse report immediately?
- A. Temperature of 100.4°F (38°C).
- B. Mild incisional pain.
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious postoperative complication. Options B, C, and D are expected findings.
A 36-year-old client tested positive for the tuberculosis antibody and was placed on isoniazid (INH) four weeks ago. The nurse would be MOST concerned if which of the following was observed?
- A. Fatigue and dark urine.
- B. Malaise and glucosuria.
- C. Proteinuria and lethargy.
- D. Diluted urine and epigastric distress.
Correct Answer: A
Rationale: initial indications of hepatic dysfunction
A client comes to the nurse's station for her antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes.
Which of the following action should the nurse take FIRST?
- A. Determine what other medications the patient is taking.
- B. Perform a neurological assessment.
- C. Administer haloperidol decanoate (Haldol D) IM stat.
- D. Administer the PRN trihexyphenidyl (Artane) IM immediately.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane