Nokea
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
- A. Chest drainage of 150 mL in the past hour
- B. Confusion and restlessness
- C. Pallor and coolness of skin
- D. Urinary output of 40 mL per hour
Correct Answer: B
Rationale: Confusion and restlessness may indicate cerebral hypoxia or other serious complications post-CABG, requiring immediate reporting.
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A client experienced a major burn over 55% of his body 36 hours ago. The client is restless and anxious, and states, 'I am in pain.' There is a physician prescription for intravenous morphine. The nurse's first action would be to:
- A. Administer the morphine
- B. Assess respirations
- C. Assess urine output
- D. Check serum potassium levels
Correct Answer: B
Rationale: Assessing respirations is critical before administering morphine, as opioids can cause respiratory depression, especially in a burn client with potential airway compromise.
A 28-year-old woman pregnant with twins comes in for her prenatal appointment. She tells the nurse that she has two children at home (ages 4 years and 16 months), and she had one abortion 6 years ago when she was 8 weeks along in the pregnancy. The nurse charts
- A. gravida 4, para 2.
- B. gravida 4, para 3.
- C. gravida 5, para 2.
- D. gravida 5, para 3.
Correct Answer: C
Rationale: Gravida counts all pregnancies (2 children, 1 abortion, current twin pregnancy = 5). Para counts deliveries after 20 weeks (2 children = 2). Twins count as one delivery.
The nurse is caring for a client with leukemia who has received the drug (daunorubicin) Cerubidine. Which of the following common side effects would cause the most concern?
- A. Nausea
- B. Vomiting
- C. Cardiotoxicity
- D. Alopecia
Correct Answer: C
Rationale: Daunorubicin is known for cardiotoxicity, which can lead to heart failure and is life-threatening, making it the most concerning side effect. Nausea, vomiting, and alopecia are common but less severe.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- A. Tire easily
- B. Grow normally
- C. Need more calories
- D. Be more susceptible to viral infections
Correct Answer: A
Rationale: A ventricular septal defect causes increased pulmonary blood flow, leading to easy tiring due to cardiac workload.
The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.