Nokea
During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for injury with compression over the xiphoid process?
- A. Lung.
- B. Liver.
- C. Stomach.
- D. Diaphragm.
Correct Answer: B
Rationale: Compressing the xiphoid process risks liver injury, as it lies directly beneath, potentially causing laceration or hemorrhage.
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The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication?
- A. valacyclovir
- B. zidovudine
- C. amphotericin b
- D. metronidazole
Correct Answer: B
Rationale: Zidovudine (AZT) is used during labor in HIV-positive clients to reduce the risk of perinatal transmission of HIV. Choice A (valacyclovir) is for herpes, Choice C (amphotericin B) is for fungal infections, and Choice D (metronidazole) is for bacterial/parasitic infections.
The nurse is preparing to apply a prescribed nitroglycerin ointment to a client. The nurse should?
- A. apply it only to the client's upper chest.
- B. rub the ointment into the client's skin until it disappears.
- C. rotate the application sites.
- D. cover the ointment with a gauze dressing.
Correct Answer: C
Rationale: Rotating sites prevents skin irritation and ensures consistent absorption.
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
- A. Placing the client on the back with a small pillow under the head.
- B. Keeping portable suctioning equipment at the bedside.
- C. Opening the client's mouth with a padded tongue blade.
- D. Cleaning the client's mouth and teeth with a toothbrush.
Correct Answer: A
Rationale: Placing the client on their back increases the risk of aspiration, especially in stroke patients with impaired swallowing. Suction equipment, padded tongue blades, and toothbrushing are appropriate for safe oral hygiene.
The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply.
- A. Nausea and vomiting
- B. Constipation
- C. Pruritus
- D. Urinary retention
- E. Nystagmus
Correct Answer: A,B,C,D
Rationale: Fentanyl, an opioid, commonly causes nausea, constipation, pruritus, and urinary retention. Nystagmus is not a typical side effect.
What should the nurse assess in a client receiving anticonvulsant therapy?
- A. Liver function.
- B. Blood pressure.
- C. Pain levels.
- D. Skin integrity.
Correct Answer: A
Rationale: Liver function is assessed due to the potential hepatotoxicity of anticonvulsant medications.