Nokea
Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A noncoring needle
Correct Answer: D
Rationale: The correct answer is D: A noncoring needle. The nurse should use a noncoring needle to access the port because it is specifically designed for this purpose. Noncoring needles have a special tip that minimizes damage to the port septum, reducing the risk of complications such as infection or port damage. An angiocatheter (A) is not ideal for accessing a port as it is designed for venipuncture, not for accessing ports. A 25-gauge needle (B) may be too small and may not provide adequate flow. A butterfly needle (C) is not recommended for accessing ports due to its design and potential for septum damage.
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Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
For each finding. click to specify if the finding is consistent with pancreatitis or peritonitis Each finding may support more than one disease process.
- A. Bloody stools
- B. Hyperbilirubinemia
- C. Abdominal pain
- D. Elevated WBC court
Correct Answer: A,B,C,D
Rationale: The correct answer is .
Rationale:
1. Bloody stools can be seen in both pancreatitis and peritonitis due to gastrointestinal bleeding.
2. Hyperbilirubinemia is a common finding in pancreatitis due to obstruction of the bile duct by edema or inflammation.
3. Abdominal pain is a hallmark symptom of both pancreatitis and peritonitis, indicating inflammation or irritation of the abdominal structures.
4. Elevated WBC count is a sign of infection or inflammation, which can be present in both pancreatitis and peritonitis.
Summary:
- Bloody stools: Supports both pancreatitis and peritonitis.
- Hyperbilirubinemia: Supports pancreatitis.
- Abdominal pain: Supports both pancreatitis and peritonitis.
- Elevated WBC count: Supports both pancreatitis and peritonitis.
Other choices are incorrect because they do not align with the typical clinical presentations of pancreatitis
The client asks the nurse if the medication can be given 2 hr. earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when it's convenient for you.
- C. I can infuse the medication at a faster rate.â€
- D. I have up to 2 hours after the usual schedule time to give you this medication.â€
Correct Answer: D
Rationale: The correct answer is D because it adheres to safe medication administration practices. The nurse should explain to the client that there is a window of up to 2 hours after the usual schedule time to administer the medication safely. This ensures that the medication remains effective while also preventing any potential harm from giving it too early or too late.
Choice A is incorrect because starting the medication 30 minutes earlier may not fall within the safe administration window. Choice B is incorrect because adjusting the time solely based on convenience may compromise the medication's effectiveness. Choice C is incorrect because infusing the medication at a faster rate could lead to adverse effects.
A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to assistive personnel?
- A. Ask the client to describe her pain.
- B. Check the client's pedal pulse on the right leg
- C. Observe the position of the suspended weight
- D. Remind the client to use the incentive spirometer.
Correct Answer: D
Rationale: Correct Answer: D. Remind the client to use the incentive spirometer.
Rationale:
1. Incentive spirometer use is a task that can be safely delegated to assistive personnel.
2. It is a non-invasive procedure and does not require advanced nursing skills.
3. Using the incentive spirometer helps prevent respiratory complications post-surgery.
4. Assistive personnel can remind the client to use it regularly, promoting lung expansion and preventing atelectasis.
Summary of other choices:
A: Asking the client to describe pain requires nursing assessment skills.
B: Checking the client's pedal pulse requires nursing assessment skills.
C: Observing the position of the suspended weight requires nursing judgment to adjust if needed.
Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.