Nokea
Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
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A toddler with Tetralogy of Fallot is hospitalized with a diagnosis of pneumonia. During the nursing assessment, the child develops a hypoxic episode. The nurse should:
- A. Provide the child his favorite toy.
- B. Place the child in a supine position.
- C. Pick the child up and comfort him.
- D. Place the child in knee chest position.
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting in Tetralogy of Fallot during hypoxia. Toys or comforting do not address hypoxia. Supine position may worsen shunting.
The nurse is assessing the client's abdomen. Which should the nurse do first?
- A. Auscultate
- B. Percuss
- C. Inspect
- D. Palpate
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
A mother brings her two-year-old boy to the pediatrician’s office.
- A. Which symptom would suggest to the nurse that a two-year-old boy has strabismus?
- B. When the child draws, he places his head close to the table.
- C. The child rubs his eyes frequently.
- D. The child closes one eye to see a poster on the wall.
- E. The child is unable to see objects in the periphery of his visual field.
Correct Answer: C
Rationale: Strabismus is characterized by misaligned visual axes, causing the brain to receive two images. Closing one eye to focus on an object, such as a poster, is a compensatory behavior indicative of strabismus. The other symptoms suggest refractive errors or other visual impairments, not strabismus.
A male client's behavior begins to escalate into aggressive behavior.
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
- A. Utilize an organized team to place the client in seclusion.
- B. Leave the client alone in his room to identify feelings of anger.
- C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
- D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion
Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?
- A. Neuro malignant syndrome
- B. Acute extrapyramidal syndrome
- C. Glaucoma, prostatic hypertrophy
- D. Parkinson's disease, atypical tremors
Correct Answer: C
Rationale: Glaucoma, prostatic hypertrophy. These are contraindications to benztropine due to its anticholinergic effects.