Nokea
For which of the following should the nurse closely assess a client who is reversing from halothane (Fluothane) general anesthesia and receiving clindamycin (Cleocin)?
- A. Tachycardia
- B. Respiratory depression
- C. Hypotension
- D. Renal failure
Correct Answer: B
Rationale: Halothane, a general anesthetic, can cause respiratory depression during recovery, which is a critical condition to monitor. Clindamycin is not strongly associated with these other effects in this context.
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The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.
- A. Check that the dose is appropriate for the child's weight.
- B. Note that the onset of the medication will be immediate.
- C. Follow the administration of the bolus of heparin with an I.V. infusion of heparin 10 units/kg/hour.
- D. Monitor partial thromboplastin time (PTT).
- E. Discontinue the penicillin until the PTT is at a therapeutic level.
Correct Answer: A,C,D
Rationale: Verifying the dose, administering a maintenance infusion, and monitoring PTT are standard for heparin therapy. Heparin's onset is immediate for I.V. but not a primary concern. Penicillin does not need discontinuation.
A client has been hospitalized with heart failure. He is receiving digoxin (Lanoxin) and furosemide (Lasix) intravenously. He tells the nurse that he hears a continuous ringing in his ears and that he has never had this problem before. What is the appropriate action for the nurse to take at this time?
- A. Obtain a digoxin level to check for toxicity
- B. Note the observation in the chart and plan to reassess in 2 hours
- C. Ask the client if he has been taking aspirin in addition to his other medications
- D. Discontinue the furosemide and notify the physician
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of digoxin toxicity, requiring immediate checking of digoxin levels. Aspirin is less likely to cause this, and discontinuing furosemide or delaying action is inappropriate.
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
- A. Pleuritic chest pain has resolved.
- B. The oxygen saturation is greater than 92%.
- C. Fluctuations in the water-seal chamber ceased.
- D. Suction in the chest drainage system is no longer needed.
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.
A client with a hip fracture is scheduled for surgery. Which preoperative teaching should the nurse include?
- A. Avoid coughing post-surgery
- B. Expect to ambulate immediately
- C. Use of incentive spirometry
- D. Limit fluid intake
Correct Answer: C
Rationale: Incentive spirometry prevents postoperative pulmonary complications like atelectasis, critical for a client with limited mobility post-hip surgery.
A client with a history of type 2 diabetes is prescribed exenatide (Byetta). The nurse should instruct the client to:
- A. Take the medication before meals.
- B. Monitor for signs of hypoglycemia.
- C. Take the medication at bedtime.
- D. Stop the medication if weight loss occurs.
Correct Answer: A, B
Rationale: Exenatide is taken before meals to control postprandial glucose, and hypoglycemia is a risk.