Nokea
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse, and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
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A four-year-old child with sickle cell anemia.
The nurse is aware that which of the following statements, if made by the parents of a four-year-old child with sickle cell anemia, indicates a need for further teaching?
- A. When my daughter complains of pain, I give her baby aspirin.'
- B. I try to keep my daughter away from people with infections.'
- C. I sometimes have to give my daughter some of her Demerol for pain.'
- D. I encourage my daughter to drink a lot of water.'
Correct Answer: A
Rationale: Strategy: 'Need for further teaching' indicates you are looking for an incorrect behavior. (1) correct-aspirin can cause a hemorrhage during a sickle cell crisis (2) important for a sickle cell client to prevent sickling crisis (3) reflects appropriate use of medication to decrease the client's pain (4) important for a sickle cell client to prevent sickling crisis
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
- A. I cannot give this medication as it is written. I have no idea of what you mean.
- B. Would you please clarify what you have written so I am sure I am reading it correctly?
- C. I am having difficulty reading your handwriting. It would save me time if you would be more careful.
- D. Please print in the future so I do not have to spend extra time attempting to read your writing.
Correct Answer: B
Rationale: Would you please clarify what you have written so I am sure I am reading it correctly? This is respectful and ensures patient safety.
The nurse is bathing a client who has contact isolation ordered. The nurse wears gloves. What else is needed?
- A. Face mask
- B. Sterile gloves
- C. Isolation cap
- D. Isolation gown
Correct Answer: D
Rationale: An isolation gown prevents contact transmission, required alongside gloves for bathing a client in contact isolation.
An infant with a positive PKU blood Test .
The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood Test ?
- A. Place the infant on Lofenlac formula.
- B. Administer medium-chain triglyceride (MCT) oil with each feeding.
- C. Provide genetic counseling for the family.
- D. Place the infant on Lorenzo's Oil treatments.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-Guthrie blood Test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine, but contains minerals and vitamins to provide a balanced nutritional formula (2) could be a plan for a child with cystic fibrosis (3) important, but is not as high a priority as answer choice #1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD)
The nurse is instructing a client being discharged on tranylcypromine sulfate (Parnate).
The nurse knows further instruction is needed if the client makes which of the following statements?
- A. To celebrate, my wife and I are going out for pepperoni pizza and wine tonight.'
- B. I plan to use sunblock at the beach this summer.'
- C. When I get home, I am going to start a diet so I can lose some weight.'
- D. Now that I feel so much better, I have more energy.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to Parnate. (1) correct-Parnate is a MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt, beer, wine) to prevent hypertensive crisis (2) sunblock required (3) no contraindication to sensible weight reduction diet (4) expected outcome of antidepressant; takes 3-4 weeks to work