Nokea
The nurse is assessing a client with an altered level of consciousness. One of the first signs of altered level of consciousness is:
- A. Inability to perform motor activities
- B. Complaints of double vision
- C. Restlessness
- D. Unequal pupil size
Correct Answer: C
Rationale: Restlessness is often an early sign of altered consciousness, indicating neurological changes before more severe symptoms appear.
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While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:
- A. Stop the medication from infusing
- B. Flush the IV catheter with normal saline
- C. Apply a tourniquet and call the doctor
- D. Continue the IV and assess the site for edema
Correct Answer: A
Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.
A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?
- A. Aldactone (spironolactone)
- B. Demadex (torsemide)
- C. Dyrenium (triamterene)
- D. Midamor (amiloride hydrochloride)
Correct Answer: B
Rationale: Demadex, a loop diuretic, causes potassium loss, increasing the risk of hypokalemia, unlike potassium-sparing diuretics like Aldactone.
A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
- A. Your infant is fine. Don't worry.
- B. Apgar scores indicate a need for extra medical care at birth. Your baby's score of 7 is fine.
- C. There are many good special education programs available I can recommend.
- D. I'll ask the physician to speak with you.
Correct Answer: B
Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Correct Answer: D
Rationale: Sulfamylon (mafenide acetate) causes a burning sensation upon application, which should be explained to the client.
The nurse is completing the preoperative checklist on a client scheduled for surgery and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask him to come see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check in the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct Answer: A
Rationale: Informed consent requires that the client understands the procedure and its risks. If the client is unclear, the surgeon, as the primary provider, should clarify the information to ensure the client's understanding, as this is a legal and ethical requirement.