Nokea
The nurse on the floor will perform peripheral IV site insertion.
Her performance is based on:
- A. Hospital policies and procedures.
- B. Nursing Standards of Practice.
- C. Doctor's orders.
- D. IV regulation developed by the Board of Nursing
Correct Answer: B
Rationale: Nursing Standards of Practice guide safe and competent IV insertion.
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The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse:
- A. Call the doctor.
- B. Stop the IV infusion of Vancomycin.
- C. Administer Benadryl as ordered.
- D. Take the vital signs.
Correct Answer: B,D,C,A
Rationale: Redness suggests an allergic reaction or 'red man syndrome' from rapid vancomycin infusion. The nurse should: stop the infusion to prevent further reaction, take vital signs to assess severity, administer Benadryl if ordered, and call the doctor for further orders.
An adult had an open cholecystectomy and has an open wound. The client refuses to look at the area during the dressing change. What is the most likely reason for this behavior?
- A. Denial of surgery
- B. Change in body image
- C. The client fears becoming nauseated at the sight of the wound.
- D. The client does not like the sight of blood.
Correct Answer: B
Rationale: Refusing to look at the wound suggests difficulty accepting a change in body image post-cholecystectomy, a common emotional response.
A client who had a total thyroidectomy this morning is to be admitted to the surgical floor. What should the nurse have readily available when the client arrives?
- A. Tracheostomy set
- B. Catheterization tray
- C. Sterile dressing set
- D. Ventilator
Correct Answer: A
Rationale: Thyroidectomy risks airway obstruction from swelling or hematoma; a tracheostomy set is essential for emergency airway management.
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:
- A. Encourage the client to drink extra fluids.
- B. Request a low-protein diet for the client.
- C. Bathe the client using only mild soap and water.
- D. Provide additional warmth for swollen and inflamed joints.
Correct Answer: A
Rationale: Cyclophosphamide is nephrotoxic; extra fluids promote excretion and reduce bladder toxicity. Low-protein diets are not indicated, mild soap is unrelated, and joints are not typically inflamed in nephrotic syndrome.
Which of the following is considered a sequela of a staphylococcal infection that may result to glomerulonephritis?
Infected burn wound
- A. Impetigo
- B. Skin problem from chickenpox
- C. Herpes simplex
Correct Answer: B
Rationale: Impetigo is a bacterial infection of the skin caused by streptococci or staphylococci. Group A hemolytic streptococci can cause rheumatic fever and glomerulonephritis.