Nokea
The doctor has ordered chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the doctor based on which of the following rationales?
- A. The nurse believes that the client's symptoms reflect alcohol withdrawal.
- B. The nurse does not know if the client is allergic to this medication.
- C. The nurse knows that the client is not psychotic.
- D. The nurse routinely checks on the doctor's orders.
Correct Answer: A
Rationale: medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences
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The nurse is teaching a client with a new diagnosis of glaucoma about timolol (Timoptic) eye drops. Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any shortness of breath.
- C. Use the drops every 4 hours.
- D. Avoid blinking after administration.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bronchospasm; shortness of breath requires reporting. Options A, C, and D are incorrect.
The nurse is supervising care given to clients on a medical/surgical unit.
The nurse should intervene if which of the following is observed?
- A. A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
- B. A nurse injects insulin through a single-lumen percutaneous central catheter for client receiving total parenteral nutrition.
- C. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
- D. A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Correct Answer: C
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) appropriate procedure, prevents airborne contamination (2) insulin is the only medication that can be given, compatible with TPN (3) correct-applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur (4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour
A client has a repair of a hiatal hernia using a thoracic approach. During the immediate post-op period, the nurse should carefully assess the client for:
- A. A change in appetite
- B. Respiratory change
- C. Anxiety
- D. Activity intolerance
Correct Answer: B
Rationale: A thoracic approach affects the chest, so respiratory changes (e.g., distress, decreased oxygen saturation) are critical to assess post-op. Appetite, anxiety, and activity intolerance are less immediate concerns.
Delirium tremens could best be described as
- A. Disorganized thinking, feelings of terror and non-purposeful behavior
- B. A generalized shaking of the body accompanied by repetitive thoughts
- C. An excited state accompanied by disorientation, hallucination and tachycardia
- D. Single or multiple jerks caused by rapid contracting muscles
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.
A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to
- A. provide an avenue for nutrients to flow past an obstructed area.
- B. prevent fluid and gas accumulation in the stomach.
- C. administer drugs that can be absorbed directly from the inTest inal mucosa.
- D. remove fluid and gas from the small inTest ine.
Correct Answer: D
Rationale: Miller-Abbott tube provides for inTest inal decompression; inTest inal tube is often used for treatment of paralytic ileus