Nokea
The nurse is assigned to care for a child who is scheduled for an appendectomy. Select the prescriptions that the nurse anticipates will be prescribed. Select one that doesn't apply.
- A. Initiate an IV line.
- B. Maintain an NPO status.
- C. Administer a Fleet enema.
- D. Administer intravenous antibiotics.
Correct Answer: C
Rationale: For a child scheduled for an appendectomy, the administration of a Fleet enema is not typically required. An IV line is often initiated for fluid and medication administration, maintaining NPO status is necessary to prevent aspiration during surgery, and administering intravenous antibiotics may be part of the preoperative regimen. Therefore, the correct choice that does not apply in this case is administering a Fleet enema.
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When assessing a patient suspected to have Hepatitis, a nurse notes the patient's eyes are yellow-tinged. Which of the following diagnostic results would further assist in confirming this diagnosis?
- A. Decreased serum Bilirubin
- B. Elevated serum ALT levels
- C. Low RBC and Hemoglobin with increased WBCs
- D. Increased Blood Urea Nitrogen level
Correct Answer: B
Rationale: Elevated serum ALT levels would further confirm the diagnosis of Hepatitis. ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes, such as ALT, often indicate liver damage. Choice A, 'Decreased serum Bilirubin,' is incorrect as elevated bilirubin levels are typically seen in hepatitis due to impaired bilirubin metabolism. Choices C and D are unrelated to confirming a diagnosis of hepatitis as they describe findings not specific to liver function or hepatitis. Low RBC and Hemoglobin with increased WBCs (Choice C) suggest a different condition like anemia or infection, not specific to liver disease. Increased Blood Urea Nitrogen level (Choice D) is more indicative of kidney function rather than liver function, thus not helpful in confirming hepatitis.
In a 24-year-old woman, the term used to define uterine bleeding in which there is no menstruation is:
- A. Oligomenorrhea
- B. Amenorrhea
- C. Menorrhagia
- D. Metrorrhagia
Correct Answer: B
Rationale: Amenorrhea is the correct term for the absence of menstrual periods in a woman of childbearing age. It is typically defined as no menstruation for at least three consecutive cycles or six months. Oligomenorrhea refers to infrequent or irregular menstrual periods rather than complete absence. Menorrhagia is characterized by excessive menstrual bleeding, not the absence of menstruation. Metrorrhagia involves irregular, acyclic bleeding between menstrual periods, which is different from the absence of menstruation.
The physician has decided to perform a thoracentesis based on Mr. R's assessment. Which of the following actions from the nurse is most appropriate?
- A. Instruct the client not to talk during the procedure
- B. Assist the client to sit upright or slightly lean forward
- C. Insert a 20-gauge needle just above the 4th intercostal space
- D. Connect the needle to suction to remove fluid that has collected in the pleural space
Correct Answer: A
Rationale: The correct answer is to instruct the client not to talk during the procedure. This is important to prevent air from being drawn into the pleural space during the thoracentesis. Choice B is incorrect because the client should be sitting upright or slightly leaning forward during the procedure to facilitate access to the pleural space. Choice C is incorrect as the nurse should not perform the thoracentesis procedure, which involves inserting a needle into the pleural space - this is the physician's responsibility. Choice D is incorrect as connecting the needle to suction to remove fluid is not the appropriate procedure for a thoracentesis. Thoracentesis is typically done to remove fluid or air for diagnostic or therapeutic purposes, not to connect to suction to remove fluid that has collected in the pleural space.
A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
- A. Should be taken in the morning
- B. May increase the client's energy level
- C. Does not need to be stored in a dark container
- D. May increase the client's heart rate
Correct Answer: A
Rationale: The correct answer is that levothyroxine (Synthroid) should be taken in the morning. Taking it in the morning can help prevent interference with the client's sleeping pattern, as one of the side effects of levothyroxine is insomnia. Choice B is incorrect because levothyroxine is actually used to treat hypothyroidism and can help increase energy levels. Choice C is incorrect as there is no specific requirement for levothyroxine to be stored in a dark container. Choice D is incorrect because levothyroxine is more likely to increase heart rate rather than decrease it.
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for a morphine drip is not working?
- A. The client complains of discomfort at the IV insertion site
- B. The client states 'I just can't get relief from my pain.'
- C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
- D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
Correct Answer: C
Rationale: The correct answer is that the level of the drug is 100 ml at 8 AM and is 80 ml at noon. With a basal rate of 10 mL per hour, a total of 40 mL should have been infused by noon, leaving only 60 mL in the container. Any amount greater than 60 mL at noon indicates that the pump is not functioning properly. Therefore, the finding of 80 mL at noon suggests the pump is not delivering the expected medication volume. Choices A and B are related to the client's symptoms and may indicate the need for pain management assessment but do not specifically indicate pump malfunction. Choice D, where the level drops to 50 mL at noon, would actually indicate that the pump is working effectively, as the expected volume has been delivered.