Nokea
A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
- A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
- B. I'll use a tongue blade to collect a small amount of stool in a clean container.
- C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
- D. I'll ask the patient if he has ingested any red meat recently.
Correct Answer: C
Rationale: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading
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A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client's therapy if which of the following occurs?
- A. The client refuses to speak and sits quietly in the room.
- B. The client becomes excitable and develops tremors.
- C. The client refuses to eat breakfast.
- D. The client sleeps 18 hours a day.
Correct Answer: B
Rationale: doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors
A client is admitted with a fractured right hip. The doctor writes an order for Buck's traction. Which of the following actions, if taken by the nurse, is MOST important?
- A. Turn the client every two hours to the unaffected side.
- B. Maintain the client in a supine position.
- C. Encourage the client to use a bedside commode.
- D. Placing a footboard on the bed.
Correct Answer: A
Rationale: immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side
A client who is a gravida 2, para 1 has been admitted for induction of labor with oxytocin (Pitocin).
It would be MOST important for the nurse to take which of the following actions?
- A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.
- B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.
- C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.
- D. Start an IV line and piggyback the Pitocin with an infusion pump.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) Pitocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct-Pitocin should always be a secondary infusion controlled by an IV pump
The nurse is making patient assignments on a medical/surgical unit. The staff includes one RN, one RN pulled from the pediatric floor, an LPN/LVN, and a nursing assistant. Which of the following patients should be assigned to the RN from the pediatric floor?
- A. A client one-day postoperative after an appendectomy.
- B. A client who had a detached retina surgically repaired 4 hours ago.
- C. A client with a Sengstaken-Blakemore tube in place.
- D. A client two-days postoperative after a laminectomy with spinal fusion.
Correct Answer: A
Rationale: stable patient with expected outcome
The nurse cares for an 8 lb, 8 oz newborn boy. The infant's history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed?
- A. Temperature 97.6°F (36.5°C).
- B. Apical pulse 140 bpm.
- C. Respirations 18.
- D. BP 80/50.
Correct Answer: C
Rationale: magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min