Nokea
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. Weight gain
- B. Dry mouth
- C. Shuffling gait
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Shuffling gait. Haloperidol is an antipsychotic medication known to cause extrapyramidal side effects like shuffling gait, which can indicate a serious movement disorder called tardive dyskinesia. Reporting this symptom promptly to the provider is crucial for early intervention. Weight gain (A) and dry mouth (B) are common side effects of many medications, including haloperidol, but they are not considered urgent to report. Sedation (D) is a common side effect of haloperidol, but it is not typically a sign of a serious adverse reaction requiring immediate attention.
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A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
- A. Monitor blood pressure every 2 hr.
- B. Attach an inline filter to the IV tubing
- C. Protect the IV bag from exposure to light.
- D. Keep calcium gluconate at the client's bedside.
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and can degrade when exposed to light, leading to the formation of toxic metabolites. By protecting the IV bag from light exposure, the nurse ensures the medication's stability and prevents potential harm to the client. Monitoring blood pressure every 2 hours (Choice A) is a standard practice for clients receiving nitroprusside but is not the most critical action. Attaching an inline filter to the IV tubing (Choice B) is important to prevent particulate matter from entering the client's bloodstream but is not specific to nitroprusside administration. Keeping calcium gluconate at the client's bedside (Choice D) is unrelated to nitroprusside administration and is not necessary for this situation.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. A noncoring needle
- B. An angiocatheter
- C. A butterfly needle
- D. A 25 gauge needle
Correct Answer: A
Rationale: The correct answer is A: A noncoring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes damage to the port septum, reducing the risk of infection and catheter damage. The noncoring needle has a special tip that creates a clean puncture without coring (cutting) the septum, ensuring proper access without compromising the integrity of the port.
Summary of why the other choices are incorrect:
B: An angiocatheter is not recommended for accessing venous access ports as it is not designed for this purpose and can cause damage to the port.
C: A butterfly needle is not suitable for accessing venous access ports as it can cause coring of the septum and increase the risk of infection.
D: A 25 gauge needle is too small and not suitable for accessing implanted venous access ports as it may not provide adequate flow rates and can lead to difficulty in accessing the port.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.
A nurse is teaching a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?
- A. A living will is a document that includes my wishes about health care decisions.'
- B. My provider will make my health care decisions if I complete advance directives.'
- C. Advance directives outline who inherits my material possessions in the event of my death.'
- D. My partner needs to be present as a witness when I sign a living will.'
Correct Answer: A
Rationale: The correct answer is A because it accurately defines a living will as a document stating the client's healthcare wishes. This shows understanding of an advance directive's purpose. Option B is incorrect because advance directives empower the client, not the provider, to make healthcare decisions. Option C is incorrect as advance directives focus on healthcare, not material possessions. Option D is incorrect as witnesses don't need to be partners, just competent adults.