Nokea
The client with varicella will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Varicella (chickenpox) is a viral infection, and antivirals like acyclovir are commonly prescribed to reduce severity and duration.
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When drawing up a dosage of subcutaneous heparin, how much air should be drawn into the syringe after the correct dosage is obtained?
- A. 1 mL
- B. 0.6 mL
- C. 0.2 to 0.3 mL
- D. 0.01 mL
Correct Answer: C
Rationale: An air lock of 0.2-0.3 mL (C) is used in subcutaneous heparin injections to ensure the full dose is delivered and to prevent leakage.
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Correct Answer: D
Rationale: A pulsatile mass in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding aorta.
A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the heparin drip rate
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of vascular assessments
Correct Answer: A
Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.
A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?
- A. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock
- B. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries
- C. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries
- D. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage
Correct Answer: C
Rationale: The ABCs of trauma care prioritize airway, breathing, and circulation. Establishing an airway comes first, followed by controlling hemorrhage and preventing shock, then assessing for head injuries.
In caring for a critically ill client with a nasogastric tube (NGT) for enteral feeding, which action by the nurse demonstrates competency in NGT care? Select all that apply.
- A. The nurse checks gastric residual every 4 hours for continuous feedings.
- B. The nurse maintains the client in a low Fowler's position during feeding.
- C. The nurse checks gastric residual before each bolus or intermittent feeding.
- D. The tubing is changed every 48 hours or when the bag appears visibly soiled.
- E. The nurse returns the residual to the stomach unless the volume is greater than 250 mL.
Correct Answer: A, C, E
Rationale: Checking residuals for continuous and bolus feedings and returning residuals (unless >250 mL) are standard. Low Fowler’s increases aspiration risk, and tubing change frequency varies by policy.