Nokea
The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients?
- A. A client awaiting surgery for a hiatal hernia repair at 11 a.m.
- B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
- C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
- D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
Correct Answer: C
Rationale: The client with sudden onset of acute stomach pain (C) should be assessed first, as this could indicate a serious complication like ulcer perforation. The other clients' conditions are less urgent: the hiatal hernia client is stable, the NPO client is awaiting tests, and the jaw surgery client's pain is expected postoperatively.
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To prepare the irrigation solution used for removal of cerumen, the nurse should use:
- A. Normal saline.
- B. Sterile water.
- C. Antiseptic solution.
- D. Warm tap water.
Correct Answer: A
Rationale: Normal saline is the preferred solution for ear irrigation, as it is isotonic and safe for the ear canal, minimizing irritation or risk of infection.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
The nurse is to administer midazolam (Versed) 2.5 mg. The medication is available in a 5 mg/mL vial. The nurse should administer ___ mL.
Correct Answer: 0.5
Rationale: To administer 2.5 mg from a 5 mg/mL vial, calculate: 2.5 mg ÷ 5 mg/mL = 0.5 mL. This is a calculation question, not multiple-choice, but included as per instructions.
A client is being prepared to have a craniotomy for a brain tumor. As a client advocate, the nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. Which of the following indicates that the nurse needs to contact the surgeon for further communication with the client?
- A. We talked about the effect of my diabetes on healing.'
- B. œThe surgeon explained how the craniotomy was done.'
- C. œThere are no major risks from this surgery.'
- D. œI will die if the tumor is not removed from my brain.'
Correct Answer: C
Rationale: Stating there are no major risks indicates a misunderstanding, as craniotomy carries significant risks (e.g., bleeding, infection). The nurse must contact the surgeon to clarify risks for informed consent.
Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply