Nokea
Following a total hip replacement, the nurse should do which of the following? Select all that apply.
- A. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours.
- B. Encourage the client to use the overhead trapeze to assist with position changes.
- C. For meals, elevate the head of the bed to 90 degrees.
- D. Use a fracture bedpan when needed by the client.
- E. When the client is in bed, prevent thromboembolism by applying thigh-high antiembolism stockings.
Correct Answer: B,D,E
Rationale: Using a trapeze, fracture bedpan, and antiembolism stockings supports recovery and prevents complications. Prone positioning and 90-degree elevation risk dislocation.
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What action should this nurse take to avoid spreading nosocomial infections?
- A. Remove the face mask.
- B. Remove the hair covering.
- C. Wash her hands before tying the strings on the mask.
- D. Tie the dangling strings of the mask around her neck.
Correct Answer: C
Rationale: Hand hygiene is critical to prevent nosocomial infections. Washing hands before handling the mask ensures the nurse does not contaminate it or transfer pathogens. Removing protective gear or tying strings improperly could increase infection risk.
The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity?
- A. constricted pupils
- B. hypertension
- C. coarse Tremors
- D. diarrhea
Correct Answer: A
Rationale: Constricted pupils (miosis) are a hallmark of opioid toxicity, including fentanyl, due to its effects on the central nervous system.
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
- A. Prepare for transcutaneous pacing.
- B. Prepare to defibrillate the client at 200 joules.
- C. Administer atropine 0.5 mg I.V. push.
- D. Schedule the operating room for insertion of a permanent pacemaker.
Correct Answer: A
Rationale: Third-degree heart block with a rate of 35 bpm and hypotension requires immediate transcutaneous pacing to restore adequate heart rate and perfusion.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
- A. Give the client a warming blanket.
- B. Administer low-dose barbiturates.
- C. Encourage the client to hyperventilate.
- D. Restrict fluids.
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.
The nurse is caring for a client with herpes simplex virus who is experiencing an outbreak. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe?
- A. Metronidazole
- B. Acyclovir
- C. Imiquimod
- D. Fluconazole
Correct Answer: B
Rationale: Acyclovir is an antiviral medication used to treat herpes simplex virus (HSV) infections. Choice A (metronidazole) is used for bacterial and parasitic infections, Choice C (antibiotic) is for topical treatment of genital warts, and Choice D (fluconazole) is an antifungal for yeast infections.