Nokea
The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?
- A. Administer epinephrine
- B. Start an IV fluid bolus
- C. Place the client in Trendelenburg position
- D. Administer oxygen via nasal cannula
Correct Answer: A
Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.
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The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied:
- A. Before the client arises in the morning
- B. With the client in a standing position
- C. After the client has bathed and applied lotion to the legs
- D. Before the client retires in the evening
Correct Answer: A
Rationale: Antithrombotic stockings should be applied before the client arises in the morning when edema is minimal, ensuring proper fit and maximum compression to promote venous return. Applying them later or after lotion can reduce effectiveness or cause skin irritation.
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
- A. D5 in normal saline
- B. D5W
- C. 0.9 normal saline
- D. D5 in lactated Ringer's
Correct Answer: C
Rationale: A concentration of 0.9 NS is used to correct extracellular fluid depletion.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.
The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Reduce his anxiety
- B. Avoid going to psychotherapy
- C. Manipulate the health team members
- D. Increase his self-image by showing higher standards than the fellow clients
Correct Answer: A
Rationale: These behaviors are attempts to relieve anxiety, as compulsive actions often serve as a coping mechanism for severe anxiety.
Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of iced tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and A), and zinc. Baked chicken breast (protein), broccoli (vitamin C), wheat roll (carbohydrates), and an orange (vitamin C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).