Nokea
In a client receiving opiate therapy, which of the following should the nurse closely monitor for in order to minimize the risk for imbalanced nutrition?
- A. Diarrhea
- B. Anorexia and nausea
- C. GI tract infection
- D. Gastric ulcer
Correct Answer: B
Rationale: The correct answer is B because opiates commonly cause gastrointestinal side effects such as nausea and anorexia, which can lead to nutritional imbalances.
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During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow to normal breaths alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems.
Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations.
Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations.
Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.
Until doctor's orders are received, the most appropriate position for Mr. Jones, admitted with retinal detachment, is lying
- A. flat on his back
- B. on his left side
- C. on his right side
- D. on his abdomen
Correct Answer: B
Rationale: Lying on the affected side (left side) helps reduce movement of the detached retina, minimizing further damage until definitive treatment can be administered.
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
- A. Low hemoglobin.
- B. Hypernatremia.
- C. High serum creatinine.
- D. Hyperkalemia.
Correct Answer: A
Rationale: Hemodialysis does not directly improve anemia caused by low hemoglobin.
When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct Answer: B
Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.
When assigning staff to patients who are receiving chemotherapy, what is the major consideration about chemotherapeutic drugs?
- A. During preparation,drugs may be absorbed through the skin or inhaled.
- B. Many chemotherapeutics are vesicants.
- C. Chemotherapeutics are frequently given through central venous access devices.
- D. Oral and venous routes are the most common.
Correct Answer: A
Rationale: Safety precautions during drug preparation are paramount due to the potential for hazardous exposure to healthcare workers.