Nokea
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
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After successful alcohol detoxification, a client remarked to a friend, 'I've tried to stop drinking but I just can't. I can't even work without having a drink.' The client's belief that he needs alcohol indicates his dependence is primarily
- A. psychological
- B. physical
- C. biological
- D. social-cultural
Correct Answer: A
Rationale: With psychological dependence, it is the client's thoughts and attitude toward alcohol that produce craving and compulsive use.
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
- A. Prepare to suction the client.
- B. Turn the client to a side-lying position.
- C. Restrain the client's upper extremities.
- D. Request assistance from other staff members.
- E. Use a tongue blade to depress the client's tongue.
Correct Answer: A,B,D
Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.
The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document?
- A. Pericardial friction rub
- B. S1, S2, no adventitious sounds
- C. S3 extra heart sound
- D. Systolic murmur
Correct Answer: C
Rationale: An S3 heart sound is commonly associated with heart failure due to fluid overload and ventricular dysfunction.
The nurse is caring for a 5-year-old client with sickle cell disease who is experiencing an episode of acute pain. The client has shortness of breath, nausea with vomiting, and severe generalized body and joint pain. Which of the following findings requires immediate intervention?
- A. enlarged spleen on palpation
- B. hemoglobin level of 9.0 g/dL (90 g/L)
- C. bilateral swelling of the hands and feet
- D. pain rated as 8 on the Wong-Baker FACES Scale
Correct Answer: A
Rationale: An enlarged spleen may indicate splenic sequestration, a life-threatening complication requiring immediate intervention.
A client is admitted to the recovery room following an exploratory laparotomy. Which medication should be kept nearby?
- A. Nitroprusside (Nipride)
- B. Naloxone hydrochloride (Narcan)
- C. Flumazenil (Romazicon)
- D. Diphenhydramine (Benadryl)
Correct Answer: B
Rationale: Naloxone (Narcan) should be kept nearby to reverse opioid-induced respiratory depression, common after surgery due to anesthesia or pain management. Nitroprusside , flumazenil , and diphenhydramine are less relevant.