Nokea
The nurse is beginning the shift and is now responsible for the following clients on the postpartum unit and has not yet made rounds on the clients. Additionally, the nurse is responsible for three other clients who are currently listed as stable. The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first?
- A. The three clients who are reported to be stable.
- B. The mother with a 4-hour-old infant with initial blood glucose of 33 mg\dL and now at 15 mg/dL.
- C. A mother who had a spontaneous vaginal delivery (SVD) client and received methylergonovine maleate (Methergine) 1 hour ago for increased bleeding.
- D. A mother with a 3-day-old who had a bilirubin level of 13 mg\dL 30 minutes ago, and is now in a 'bili blanket' at the mother's bedside.
Correct Answer: B
Rationale: The infant with a blood glucose of $15 \mathrm{mg} / \mathrm{dL}$ is critically low, indicating severe hypoglycemia, which requires immediate intervention to prevent neurological damage.
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A client with a diagnosis of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following serious side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Dry mouth.
- D. Insomnia.
Correct Answer: B
Rationale: Clozapine can cause agranulocytosis, a life-threatening reduction in white blood cells, requiring regular monitoring of white cell counts.
Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
- A. Tinnitus
- B. Ecchymoses
- C. Increased pulse rate
- D. Decreased blood pressure
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
- A. Provide the client with oral hygiene.
- B. Offer the client liquids to drink.
- C. Encourage the client to cough and deep breathe.
- D. Auscultate the client's bowel sounds.
Correct Answer: A
Rationale: Oral hygiene removes residual tube-related irritation and promotes comfort after NG tube removal.
Which site or technique would you expect to use to administer ferrous sulfate?
- A. A subcutaneous injection site
- B. The PQRST technique
- C. The Z track technique
- D. The sublingual site
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
- A. A percutaneous, non tunneled subclavian catheter
- B. A peripheral intravenous catheter that is 20 gauge
- C. A multi lumen implanted tunneled and cuffed central venous catheter
- D. A peripherally inserted central venous catheter
Correct Answer: C
Rationale: A multi-lumen tunneled and cuffed central venous catheter is ideal for long-term therapy due to its durability and lower infection risk.