Nokea
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Some increase in the serum hemoglobin
- D. A little decrease in the serum potassium
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
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The spouse of a client who had an angioplasty following a heart attack says to the nurse, 'What is an angioplasty? It sounds like plastic surgery. My husband had a heart attack.' What information should be included in the nurse's response?
- A. An angioplasty repairs the heart damage caused by the heart attack.
- B. During an angioplasty, the physician creates a bypass around blocked arteries, increasing the blood flow to the heart muscle.
- C. Angioplasty is a diagnostic procedure to see if there are any blocked coronary arteries.
- D. During an angioplasty, the physician uses a balloon-tipped catheter to open up an artery that is blocked by a clot, thus increasing blood flow to the heart muscle.
Correct Answer: D
Rationale: An angioplasty is the insertion of a balloon-tipped catheter into a coronary artery. The balloon is inflated, opening up the artery and increasing blood flow through the coronary artery to the heart muscle. Angioplasty does not repair heart damage. A left heart cardiac catheterization is the diagnostic procedure that precedes angioplasty. Answer 2 describes a coronary artery bypass graft (CABG) procedure.
The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?
- A. Elevate the foot of the bed
- B. Apply knee high support stockings
- C. Encourage passive exercises
- D. Prevent pressure at back of knees
Correct Answer: D
Rationale: Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.
The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to perform arm exercises.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging arm exercises is the priority to prevent lymphedema and restore mobility post-mastectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow mobility promotion.
An adult who has myasthenia gravis is about to be discharged. Neostigmine is prescribed for her. What should the nurse include when teaching the client about this drug? Tell the client to take the drug:
- A. one-half hour before meals.
- B. between meals.
- C. immediately following meals.
- D. upon arising and at bedtime.
Correct Answer: A
Rationale: Taking neostigmine 30 minutes before meals maximizes muscle strength for chewing and swallowing, critical for myasthenia gravis patients, unlike other timing.
A nursing assistant states that her five-year-old child has developed chickenpox.
It would be MOST important for the nurse to ask which of the following questions?
- A. Have your other children had chickenpox?'
- B. Does your child have a temperature?'
- C. Have you had the chickenpox?'
- D. Do you have someone to watch your child?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates there may be more than one answer that you would like to select. Remember, you can only ask one question. (1) chickenpox spread by direct contact, airborne route; not the most important question (2) fever, malaise, and anorexia occur during first 24 hours; treat with Tylenol (3) correct-need to ascertain if staff has had the disease; if not, VZIG can be given; exclude from patient care from the 10th day after first exposure through the 21st day (28th day if VZIG given) after last exposure (4) important information, but assessing staff is most important