Nokea
The client in the emergency department requires sutures for a laceration on the left leg. Which information is most pertinent prior to suturing the wound?
- A. The client tells the nurse she has never had sutures.
- B. The spouse refuses to leave the room during suturing.
- C. The client shares she is scared of needles.
- D. The client reports hives after having dental surgery.
Correct Answer: D
Rationale: Hives post-dental surgery suggest a possible local anesthetic allergy, critical to know before suturing to avoid anaphylaxis.
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For which client should the nurse question administering the muscarinic cholinergic agonist oxybutynin (Ditropan)?
- A. The client diagnosed with overactive bladder.
- B. The client diagnosed with type 2 diabetes.
- C. The client diagnosed with glaucoma.
- D. The client diagnosed with peripheral vascular disease.
Correct Answer: C
Rationale: Oxybutynin’s anticholinergic effects can increase intraocular pressure, contraindicating it in glaucoma. It’s appropriate for overactive bladder; diabetes or PVD are not contraindications.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.
An elderly adult is scheduled for repair of a fractured femur this morning. The nurse goes in to administer the preoperative medication of Demerol 75 mg and atropine 0.4 mg IM. The client asks the nurse if he should take his eye drops before surgery. What is the best initial response for the nurse to make?
- A. You can take them when you get back from surgery.
- B. I'll give them to you now.
- C. Let me check with your physician.
- D. What kind of eye drops are you taking?
Correct Answer: D
Rationale: Knowing the type of eye drops (e.g., for glaucoma or infection) determines if they are critical pre-surgery, guiding further action.
A 19-year-old woman has just started taking birth control pills. She calls the clinic nurse to say that her breasts are tender and she is nauseous. The nurse's response is based on which understanding?
- A. These are serious side effects.
- B. These effects usually decrease after three to six cycles.
- C. Taking the pill in the morning reduces its side effects.
- D. Taking the pills every other day reduces its side effects.
Correct Answer: B
Rationale: Breast tenderness and nausea are common initial side effects of oral contraceptives, typically resolving after a few cycles.
A 5 year-old has been rushed to the emergency room several hours after acetaminophen poisoning. Which laboratory result should receive attention by the nurse?
- A. Sedimentation rate
- B. Profile 2
- C. Bilirubin
- D. Neutrophils
Correct Answer: C
Rationale: Bilirubin. Bilirubin, along with liver enzymes ALT and AST, may rise in the second stage (1-3 days) after a significant overdose, indicating cellular necrosis and liver dysfunction.