Nokea
The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
- A. Intravenously
- B. Rectally
- C. Intramuscularly
- D. Into the cerebrospinal fluid
Correct Answer: D
Rationale: Intrathecal administration involves delivering medication directly into the cerebrospinal fluid, typically via a spinal injection, to target the central nervous system effectively.
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The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:
- A. The need for oxygen therapy
- B. A history of claustrophobia
- C. A permanent pacemaker
- D. Sensory deafness
Correct Answer: C
Rationale: A permanent pacemaker is a contraindication for an MRI due to the risk of device malfunction in a magnetic field.
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
- A. Using oil- or cream-based soaps
- B. Flossing between the teeth
- C. The intake of salt
- D. Using an electric razor
Correct Answer: B
Rationale: Flossing can cause gum bleeding, increasing infection and bleeding risks in leukemia clients with low platelet counts.
A infant weighs 7 pounds at birth. The expected weight by 1 year should be:
- A. 10 pounds
- B. 12 pounds
- C. 18 pounds
- D. 21 pounds
Correct Answer: D
Rationale: Infants typically triple their birth weight by 1 year, so a 7-pound infant should weigh approximately 21 pounds.
A 19-year-old female comes into the women's clinic for an STD test. The nurse explains all of the following confirmed cases of STDs must be reported to the Centers for Disease Control (CDC) EXCEPT
- A. genital herpes.
- B. chlamydia.
- C. hepatitis B.
- D. gonorrhea.
Correct Answer: A
Rationale: Chlamydia, gonorrhea, and hepatitis B are reportable to the CDC. Genital herpes is not nationally reportable, though local regulations may vary.
A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. 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 Coumadin dosage
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of neurological assessments
Correct Answer: A
Rationale: A Protime of 120 seconds indicates excessive anticoagulation, increasing the risk of bleeding, so assessing for abnormal bleeding is the most important intervention.