Nokea
The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on applying epinephrine, which statements by the parent indicate correct understanding? Select all that apply.
- A. I will give the injection if my child has trouble breathing after a bee sting
- B. I will give the injection in the upper arm
- C. I will keep an epinephrine injection close to my child at all times
- D. I will take my child to the emergency room after giving the injection
- E. The injection can be given through clothing
Correct Answer: A,C,D,E
Rationale: Epinephrine is given for breathing difficulty, kept accessible, followed by ER visit, and can be administered through clothing. The correct site is the thigh, not the upper arm, making B incorrect.
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Which of these clients would be most appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
- B. A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia
- C. A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
- D. A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
Correct Answer: C
Rationale: This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability.
The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?
- A. Autonomy
- B. Nonmaleficence
- C. Paternalism
- D. Veracity
Correct Answer: B
Rationale: Nonmaleficence (do no harm) was violated by discharging the client under narcotic influence without ensuring safe transport, leading to harm. Autonomy, paternalism, and veracity are not primarily affected.
During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.
- A. Compare current mental status to previous findings
- B. Encourage the client to ambulate in the hallway
- C. Hold the client's morning dose of lactulose
- D. Monitor the client's ammonia level
- E. Observe the client's hand movements with the arms extended
Correct Answer: A,D,E
Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.
The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?
- A. Apply a gauze wrap and elastic stockinette around the IV site
- B. Apply a mitt on the right hand
- C. Apply a soft wrist restraint on the right wrist
- D. Apply an arm board to the left arm
Correct Answer: D
Rationale: An arm board on the left arm stabilizes the IV site, reducing pulling without restraining the client, aligning with least-restrictive interventions. Mitts or restraints on the right side do not protect the left-sided IV.
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by reversing dilation of cerebral blood vessels. Which physician prescription would the nurse expect to accomplish this?
- A. Hyperventilation per mechanical ventilation
- B. Insertion of a ventricular shunt
- C. Furosemide (Lasix)
- D. Methylprednisolone (Solu-Medrol)
Correct Answer: A
Rationale: Hyperventilation is utilized to decrease the PCO2 to 27-30, producing cerebral blood vessel constriction. Answers B, C, and D can decrease cerebral edema, but not by constriction of cerebral blood vessels; therefore, they are wrong.