Nokea
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
- A. Pedal pulses regular
- B. Urinary output 20 mL in the past hour
- C. Blood pressure 108/50
- D. Oxygen saturation 97%
Correct Answer: B
Rationale: Low urinary output (20 mL/hour) may indicate renal impairment or hypoperfusion, requiring further investigation.
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The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
- A. Notifying the physician
- B. Performing tracheal suctioning
- C. Repositioning the client to the left side
- D. Rechecking the client's O2 saturation
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?
- A. A client 2 days post-appendectomy
- B. A client 1 week post-thyroidectomy
- C. A client 3 days post-splenectomy
- D. A client 2 days post-thoracotomy
Correct Answer: D
Rationale: A post-thoracotomy patient requires RN monitoring for respiratory complications.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John's wort seldom relieves depression.
- B. She should avoid eating aged cheese.
- C. Skin reactions increase with the use of sunscreen.
- D. The herbal is safe to use with other antidepressants.
Correct Answer: C
Rationale: St. John's wort can cause photosensitivity, increasing the risk of skin reactions, so sunscreen use is recommended, not avoided.
A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Call the physician to question the prescription order
- B. Try to obtain samples for the client to take home
- C. Perform discharge teaching regarding this drug
- D. Consult social services for financial assistance with obtaining the drug
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which can exacerbate ischemia. The nurse should question the prescription.
The nurse must administer 120 mg of amoxicillin oral suspension to a child. However, the only dosage available in the pharmacy is 200 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using a whole number only.
Correct Answer: 3
Rationale: Dose = 120 mg, concentration = 200 mg/5 mL = 40 mg/mL. Volume = 120 m/40 mg/mL = 3 mL.