Nokea
The first thing that you should do immediately after a client accident is to:
- A. Notify the doctor.
- B. Render care.
- C. Assess the client.
- D. Notify the nurse manager.
Correct Answer: C
Rationale: The first action after a client accident is to assess the client to determine the extent of injury and immediate needs, following the nursing process.
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A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hyperkalemia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
The nurse is evaluating the effectiveness of antimicrobial therapy for a client diagnosed with infective endocarditis. The nurse determines that which finding is the least reliable indicator of effectiveness?
- A. Clear breath sounds
- B. Systolic heart murmur
- C. Temperature of 98.8°F
- D. Negative blood cultures
Correct Answer: B
Rationale: A systolic heart murmur, once present in the client, will not resolve spontaneously and is therefore the least reliable indicator. Clear breath sounds are a normal finding, and in this instance could mean resolution of heart failure, if that was accompanying the endocarditis. Negative blood cultures and normothermia indicate resolution of infection.
The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do which of the following. Select all that apply.
- A. Assure that the oxygen is not blowing directly on the infant’s face.
- B. Place the butterfl y mobile on the outside of the hood.
- C. Immobilize the infant with restraints.
- D. Remove the hood for 10 minutes every hour.
- E. Encourage the parents to visit the child.
Correct Answer: A,B,E
Rationale: When an oxygen hood is used, the nurse should be sure the oxygen source is not directed on the infant’s face to avoid skin irritation. Mobiles can be used to provide visual stimulation, but they should not be placed inside of the hood where they are a potential choking hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the physician has written the order. There should be as little movement in and out of the hood as possible in order to maintain the warm and humid oxygen levels. The nurse should encourage the parents to visit the child and provide verbal and tactile stimulation.
A 9-year-old child is scheduled for an electromyelogram. To prepare the child for this procedure, what should the nurse do?
- A. Wait until just before the test to tell the child what will be done.
- B. Ask the child to draw a picture of the body structures involved.
- C. Show the child the equipment that will be used in the test.
- D. Verbally explain what will be done during the test.
Correct Answer: D
Rationale: A verbal explanation in age-appropriate terms helps a 9-year-old understand the procedure, reducing anxiety and promoting cooperation.
The nurse should give which medication instructions to the client prescribed quinapril hydrochloride?
- A. Take the medication with food only.
- B. Expect a therapeutic effect immediately.
- C. Discontinue the medication if nausea occurs.
- D. Rise slowly from a lying to a sitting position.
Correct Answer: D
Rationale: Quinapril hydrochloride is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. A full therapeutic effect may be noted in 1 to 2 weeks. If nausea occurs, the client should be instructed to take a noncola carbonated beverage and salted crackers or dry toast.