Nokea
In which of the following clients is an autotransfusion contraindicated?
- A. The client who has cancer.
- B. The client who is in danger of cardiac arrest.
- C. The client with a contaminated wound.
- D. The client with a ruptured bowel.
Correct Answer: A,C,D
Rationale: Autotransfusion is contraindicated in cancer (risk of spreading malignant cells), contaminated wounds, or ruptured bowel (risk of infection or bacterial spread). It may be used cautiously in cardiac arrest if no other contraindications exist.
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A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high uric acid levels. Which of the following indicate the client is experiencing adverse effect(s) of this drug? Select all that apply.
- A. Nausea.
- B. Rash.
- C. Constipation.
- D. Flushed skin.
- E. Bone marrow depression.
Correct Answer: A,B,E
Rationale: Nausea, rash, and bone marrow depression are known adverse effects of allopurinol, indicating potential toxicity or allergic reactions.
The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication?
- A. 19 gauge, 1 1/2" (3.8 cm) needle
- B. 18 gauge, 1" (2.5 cm) needle
- C. 20 gauge, 1" (2.5 cm) needle
- D. 25 gauge, 5/8" (1.6 cm) needle
Correct Answer: D
Rationale: A 25-gauge, 5/8" needle is appropriate for neonates due to their small muscle mass and thin subcutaneous tissue, minimizing trauma.
A client with Raynaud's phenomenon is prescribed diltiazem (Cardizem). An expected outcome is:
- A. Decreased heart rate
- B. A return to normal sinus rhythm
- C. Reduced episodes of finger numbness
- D. Increased SpO2
Correct Answer: C
Rationale: Diltiazem, a calcium channel blocker, reduces vasospasm in Raynaud's by promoting vasodilation, decreasing episodes of finger numbness. It may lower heart rate or affect rhythm, but these are not primary goals, and SpO2 is not directly improved.
The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client?
- A. Breathe in normally through your nose for 2 counts (while counting to yourself, one, two).
- B. Relax your neck and shoulder muscles.
- C. Pucker your lips as if you were going to whistle.
- D. Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four).
Correct Answer: B,A,C,D
Rationale: The correct order for pursed-lip breathing is: relax muscles (B), inhale through nose for 2 counts (A), pucker lips (C), exhale through pursed lips for 4 counts (D). This prolongs exhalation, reducing air trapping.
A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to:
- A. Apply a high-quality corn plaster to the area.
- B. Consult a physician or podiatrist about removing the corns.
- C. Apply iodine to the corns before peeling them off.
- D. Soak the feet in borax solution to peel off the corns.
Correct Answer: B
Rationale: Corns should be professionally removed by a physician or podiatrist to avoid injury or infection, especially in diabetic clients with poor healing.