Nokea
The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:
- A. Loss of coordination
- B. Respiratory depression
- C. Visual hallucinations
- D. Tachycardia
Correct Answer: B
Rationale: A blood alcohol concentration of 460 mg/dL (0.46%) is life-threatening, with respiratory depression being the priority due to its potential to cause death.
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If a client has had repair of a right fractured hip and has an overhead trapeze on the bed to assist with movement, which of the following instructions should the client receive about use of the assistive device? Select all that apply.
- A. The client should always grasp the bar with both hands before moving.
- B. The client should grasp the bar with the left hand and place the right hand flat on the bed to assist movement.
- C. The client should flex the left hip and knee and place the foot flat on the bed before moving.
- D. The client should keep the left hip and knee extended when moving.
Correct Answer: A,C
Rationale: Using both hands on the trapeze (A) and flexing the left leg (C) assist safe movement post-right hip repair. Using one hand (B) or keeping the leg extended (D) is less effective.
A client is scheduled for a colposcopy. The nurse assists the client into which position?
- A. Sim's position
- B. supine position, with the head of the bed elevated 15 degrees
- C. left-side-lying position, knees to chest
- D. lithotomy position
Correct Answer: D
Rationale: Colposcopy requires the lithotomy position to provide access to the cervix for examination.
A client is admitted to the hospital with seizures. The client has jerking of the right arm and twitching of the face, but is alert and aware of the seizure. This behavior is characteristic of which type of seizure?
- A. Absence
- B. Complex partial
- C. Simple partial
- D. Tonic-clonic
Correct Answer: C
Rationale: Simple partial seizures involve focal symptoms (e.g., jerking of one arm, facial twitching) without loss of consciousness, unlike complex partial or tonic-clonic seizures. Absence seizures typically involve brief staring spells.
The nurse receives an order to administer 1,500 mL D5W IV over 12 hours. The drop factor is 15 drops/1 mL. The IV flow rate should be set at how many drops per minute? Round to the nearest whole number.
Correct Answer: 31
Rationale: Flow rate (drops/min) = (volume × drop factor) ÷ time. Calculation: (1,500 mL × 15 drops/mL) ÷ (12 × 60) = 22,500 ÷ 720 ≈ 31 drops/min.
The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?
- A. a client who is post-op day 2 from a spinal fusion at L34 with a pain level of 4 on a scale of 1-10
- B. a client with a peripheral IV on a 6-hour infusion with 42 cc remaining
- C. a client who is 6 hours post-atrial fibrillation ablation, is agitated, has a HR of 130 with B/P at 90/50, and has a urine output of 30 cc in the last 2 hours
- D. a client with a nasogastric tube in place who is complaining of gastric distress
Correct Answer: C
Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.