Nokea
The adolescent is brought to the ED with wheezing, nystagmus, ataxia, and sensorimotor neuropathy after inhaling paint thinner by “bagging.†Which nursing intervention is priority?
- A. Monitor the client's cardiac rhythm.
- B. Place the client on seizure precautions.
- C. Apply oxygen via nasal cannula at 4 liters.
- D. Notify lab to obtain a toxicology screen.
Correct Answer: C
Rationale: Applying oxygen is the priority to address wheezing and potential oxygen displacement from inhalant use.
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The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the PN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?
- A. The LPN clarifies the severity of the Penicillin allergy.
- B. The LPN discusses the order with the care team prior to administering Cefazolin.
- C. The LPN administers all ordered medications except for the Cefazolin.
- D. The LPN monitors the client after a test dose of Cefazolin is administered.
Correct Answer: C
Rationale: The LPN should clarify the order with the care team prior to determining the medication should not be given. Even though the client may have a potential reaction due to the Penicillin allergy, the therapeutic benefits of the antibiotic may outweigh the allergic reaction.
The client taking imipramine is preparing for a summer vacation. Which information should the nurse include when planning client education regarding imipramine? Select all that apply.
- A. Drink additional fluids and add extra fiber to the diet
- B. Stop imipramine if experiencing any unpleasant side effects.
- C. Avoid alcohol, which can cause an additive depressant effect.
- D. Request an “as needed†sleeping pill in the event of insomnia.
- E. Wear sunglasses, protective clothing, and sunscreen while outdoors.
Correct Answer: A,C,E
Rationale: TCAs such as imipramine (Tofranil) may cause constipation, CNS depression when combined with alcohol, and photosensitivity. Increasing fluids and fiber, avoiding alcohol, and using sun protection are appropriate.
Which of these is not a symptom of Serotonin Syndrome?
- A. edema
- B. fever
- C. confusion
- D. tremors
Correct Answer: A
Rationale: Serotonin syndrome, caused by an excess of serotonin, causes altered mental status (confusion), neuromuscular abnormalities (tremors), and/or autonomic dysfunction (fever). Edema is not a typical symptom.
Which of the following is not a nursing responsibility when preparing the client for central line insertion?
- A. advancing the guidewire
- B. explaining the procedure to the client
- C. maintaining sterile technique
- D. ensuring necessary consents are signed
Correct Answer: A
Rationale: The nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. The guidewire will be advanced by the practitioner inserting the central line.
The initial treatment regimen of isoniazid, rifampin, and ethambutol is prescribed for the adolescent who has a positive tuberculin skin test. The client confides that she thinks she may be pregnant and asks if she should be taking these medications. Which rationale should be the basis for the nurse's response?
- A. These drugs cross the placental barrier, and treatment should be withheld until the postpartum period.
- B. The medications should be taken, but the diagnosis is an indication for termination of the pregnancy.
- C. The medications should be postponed because the risk for hepatitis is greatly increased in the intrapartum period.
- D. The medications should be taken; untreated TB represents a far greater hazard to the pregnant woman and her fetus.
Correct Answer: D
Rationale: A: The medications do not cross the placental barrier, so treatment should not be withheld. B: Administering antituberculosis medications would not be an indication for termination of pregnancy because the medications are safe during pregnancy. C: The risk of hepatitis is slightly increased with the use of antituberculosis medications in pregnant women; however, the benefits of treatment strongly outweigh postponement of treatment. D: Infants born to women with untreated TB may be of lower birth weight, but rarely would the infant acquire congenital TB. Isoniazid (Nydrazid), rifampin (Rifadin), and ethambutol (Myambutol) are all considered safe for use in pregnancy.