Nokea
The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
- A. Elevate the head of the bed and apply ice to the eye
- B. Place the client in a supine position and apply heat to the knee
- C. Insert a Foley catheter and measure the intake and output
- D. Perform a vaginal exam and check for a discharge
Correct Answer: A
Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.
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The physician has ordered injections of Neumega (oprellvekin) for a client receiving chemotherapy for prostate cancer. Which finding suggests that the medication is having its desired effect?
- A. Hct 12.8 g
- B. Platelets 250,000 mm³
- C. Neutrophils 4,000 mm³
- D. RBC 4.7 million
Correct Answer: B
Rationale: Neumega (oprelvekin) stimulates platelet production, so a platelet count of 250,000 mm³ indicates effectiveness.
A nurse on the orthopedics floor is asked by another nurse to witness her waste 1 mg of morphine. The nurse draws the full 2 mg dose of morphine into the syringe and tells the first nurse, 'This client does not get enough pain relief with 1 mg of morphine, so I just go ahead and give 2 mg to keep him comfortable because the doctor won't change the dose.' Which is the correct action by the first nurse?
- A. tell the other nurse to call the doctor back and request an increase in the dosage
- B. refuse to sign off on the waste and report the incident to the charge nurse or unit manager
- C. sign off the waste, and suggest that the nurse give it over two separate doses 30 minutes apart
- D. sign off the waste, but tell the nurse to give it slowly to be sure that the client can tolerate the dose
Correct Answer: B
Rationale: Administering an unordered dose is a medication error and potential diversion. Refusing to sign and reporting ensures patient safety and accountability.
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
- A. I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.
- B. I will need to schedule a home visit for PKU screening when the baby is 3 days old.
- C. I will remind the midwife to save a specimen of cord blood for the PKU test.
- D. I will have the PKU test done when I take her for her first immunizations.
Correct Answer: B
Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.
The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to rest
- B. Resting in supine position
- C. Sitting in a straight chair
- D. Sleeping in right Sim's position
Correct Answer: C
Rationale: Sitting in a straight chair can compress the graft, impairing blood flow, and should be avoided to promote graft patency.
Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
- A. A granola bar
- B. A bran muffin
- C. Yogurt
- D. Raisins
Correct Answer: C
Rationale: Yogurt is rich in calcium, which is essential for bone health in osteoporosis management.