Nokea
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
- A. Providing instructions for medical follow-up
- B. Obtaining appropriate counseling for the victim
- C. Providing anticipatory guidance for police investigations, medical questions, and court proceedings
- D. Exploring safety concerns by obtaining permission to notify significant others who can provide shelter
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
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A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
- A. Give 600 mg of acetaminophen (Tylenol) rectally, as ordered.
- B. Inspect the child's throat for redness and swelling.
- C. Have an appropriate-sized tracheostomy tube readily available.
- D. Obtain a specimen for a throat culture.
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.
The nurse is administering a dose of ondansetron hydrochloride to a client for nausea and vomiting. Which frequent side effect of this medication should the nurse instruct the client to report?
- A. Dizziness
- B. Blurred vision
- C. A warm feeling
- D. Urinary frequency
Correct Answer: A
Rationale: Ondansetron hydrochloride is a selective receptor antagonist used as an antinausea and antiemetic. Frequent side effects include anxiety, drowsiness, dizziness, headache, fatigue, constipation, diarrhea, urinary retention, and hypoxia. Occasional side effects include abdominal pain, diminished saliva secretion, fever, feeling cold, paresthesia, and weakness. Rare side effects include hypersensitivity reaction and blurred vision.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed sotalol (Betapace). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Hyperglycemia.
- D. Weight gain.
Correct Answer: B
Rationale: Sotalol, a beta-blocker, can cause bradycardia, requiring close monitoring of heart rate.
The nurse has an order to administer ampicillin (Omnipen) 250 mg I.M. After reconstituting the ampicillin with sterile water for injection, the solution available is 500 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL.
- B. 1 mL.
- C. 2 mL.
- D. 1.5 mL.
Correct Answer: A
Rationale: To administer 250 mg from a 500 mg/mL solution, the calculation is 250 mg / 500 mg/mL = 0.5 mL.
The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
- A. The urethra
- B. A lower abdominal incision
- C. An upper abdominal incision
- D. An incision made in the perineal area
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.