Nokea
During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint?
- A. An infant with septicemia.
- B. A child with a tonsillectomy.
- C. An infant with cleft lip repair.
- D. A child with meningitis.
Correct Answer: C
Rationale: arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line
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The client with cancer of the larynx is admitted to the unit with Acute Respiratory Distress Syndrome. Which nursing diagnosis should receive priority?
- A. Alteration in oxygen perfusion
- B. Alteration in comfort/pain
- C. Alteration in mobility
- D. Alteration in sensory perception
Correct Answer: A
Rationale: Acute Respiratory Distress Syndrome causes severe hypoxemia, making alteration in oxygen perfusion the priority nursing diagnosis to ensure adequate oxygenation. Pain , mobility , and sensory perception are secondary in this life-threatening condition.
The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute.
- A. Which medication should the nurse expect to administer for a client with coupled PVCs greater than 10 per minute?
- B. Atropine sulfate (Atropine) IV.
- C. Isoproterenol (Isuprel) IV.
- D. Verapamil (Calan) IV.
- E. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent or coupled PVCs, as it suppresses ventricular arrhythmias that could lead to ventricular tachycardia. Atropine treats bradycardia, isoproterenol is used for heart block, and verapamil is a calcium-channel blocker for supraventricular arrhythmias.
The nurse is caring for a client following removal of the thyroid. Immediately post-op the nurse should:
- A. Maintain the client in a semi-Fowler's position with her head and neck supported by pillows.
- B. Encourage the client to turn her head side to side to promote drainage of oral secretions.
- C. Maintain the client in a supine position with sandbags placed on either side of her head and neck.
- D. Encourage the client to cough and deep breathe every 2 hours with her neck in a flexed position.
Correct Answer: A
Rationale: Semi-Fowler's position reduces swelling and supports the surgical site post-thyroidectomy. Turning the head or flexing the neck risks wound dehiscence. Supine with sandbags is unnecessary and uncomfortable.
A client receives morphine sulfate after being admitted to the emergency room in acute respiratory distress. He is very anxious, edematous, and cyanotic. Which of the following should the nurse recognize as the desired response to the medication?
- A. Increase in pulse pressure.
- B. Decrease in anxiety.
- C. Depression of the sympathetic nervous system.
- D. Enhanced ventilation and decreased cyanosis.
Correct Answer: B
Rationale: morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema
The nurse is caring for clients in the student health center.
- A. What is the best response by the nurse to a client whose boyfriend Test ed positive for hepatitis B?
- B. That must have been a real shock to you.'
- C. You should be Test ed for hepatitis B.'
- D. You’ll receive the hepatitis B immune globulin (HBIG).'
- E. Have you had unprotected sex with your boyfriend?'
Correct Answer: D
Rationale: The nurse should first assess the client’s exposure risk, as hepatitis B is transmitted through sexual contact or parenteral routes. Asking about unprotected sex determines the need for Test ing or prophylaxis. Empathizing, recommending Test ing, or discussing HBIG are secondary to assessing exposure.