Nokea
The nurse is caring for a child diagnosed with Tetralogy of Fallot. The client has had multiple hypercyanotic episodes (tet spells). The nurse anticipates that the physician will prescribe
- A. morphine sulfate
- B. adenosine
- C. diltiazem
- D. atropine sulfate
Correct Answer: A
Rationale: Morphine sulfate is used to manage tet spells by reducing oxygen demand and relaxing the child.
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The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement?
- A. steak and a baked potato
- B. brussels sprouts and a whole grain roll
- C. white rice with chicken
- D. ham sandwich with tomato soup
Correct Answer: B
Rationale: Brussels sprouts and whole grain rolls are high in fiber, promoting bowel movements.
The charge nurse has received a change-of-shift report on the following clients in the maternity unit. The nurse should first assess the client who
- A. delivered a term newborn 2 days ago and reports sweating and increased urinary frequency
- B. is 15 weeks pregnant and is being treated for hyperemesis gravidarum and reports increased nausea following a meal
- C. is 32 weeks pregnant and admitted 2 hours ago with placenta previa, who reports increased lower back pain
- D. is in the first stage of labor, and the most recent fetal heart rate pattern showed early decelerations
Correct Answer: C
Rationale: Increased lower back pain in a client with placenta previa at 32 weeks suggests possible complications like bleeding, requiring immediate assessment.
The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions?
- A. Rubeola
- B. Psoriasis
- C. Pediculosis
- D. Rubella
- E. Scabies
- F. Clostridium difficile
Correct Answer: C, E, F
Rationale: Pediculosis, scabies, and Clostridium difficile require contact precautions due to direct contact transmission.
The med-surge nurse receives a report on a client who is legally blind. Which action by the nurse would be most likely to reduce this client's anxiety?
- A. Assign the client to a private room.
- B. Orient the client to their room.
- C. Request for a sitter to be assigned.
- D. Instruct the UAP to check on the client frequently.
Correct Answer: B
Rationale: Orienting a legally blind client to their room reduces anxiety by promoting safety and familiarity.
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
- A. shivering
- B. hyperglycemia
- C. tachycardia
- D. bradypnea
Correct Answer: C
Rationale: Tachycardia is an early sign of cold stress as the infant attempts to increase metabolism to maintain body temperature.