Nokea
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:
- A. Apply a tourniquet to the client's arm.
- B. Administer an anticonvulsant medication.
- C. Ask the client if he is allergic to shell fish.
- D. Apply a blood pressure cuff to the arm.
Correct Answer: D
Rationale: Applying a blood pressure cuff allows monitoring of vital signs during ECT, which is a standard safety measure.
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The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.
If a nurse accidentally punctures a finger with a needle after withdrawing blood from a client, which of the following actions should be carried out first?
- A. Notify a supervisor.
- B. Wash the puncture area with soap and water.
- C. Apply pressure to the wound.
- D. File an incident/injury report.
Correct Answer: B
Rationale: Washing the puncture with soap and water (B) is the first step to reduce infection risk. Other actions (A, C, D) follow.
The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indicator of the tube's stomach placement?
- A. Aspiration of tan-colored mucus
- B. Green aspirate with a pH of 3
- C. A swish auscultated with the injection of air
- D. Bubbling in a cup of NS when the end of the tube is placed in the cup
Correct Answer: B
Rationale: A green aspirate with a pH of 3 confirms gastric placement, as stomach contents are acidic and often green due to bile, providing the most reliable indicator.
A client who has undergone a thyroidectomy complains of numbness, tingling, and stiffness in her hands, feet, and face as well as muscle tremors, spasmodic muscle contractions, and anxiety during the postoperative period. Which laboratory tests does the nurse anticipate that the physician will request?
- A. Hemoglobin.
- B. Sodium.
- C. Thyroid-stimulating hormone (TSH).
- D. Calcium.
Correct Answer: D
Rationale: Numbness, tingling, and muscle spasms post-thyroidectomy suggest hypocalcemia due to parathyroid gland disruption. The physician will likely request a calcium level test (D). Hemoglobin (A), sodium (B), and TSH (C) are not directly related to these symptoms.
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU, so the client's statement indicates a need for further teaching.