Nokea
The nurse is caring for a client on airborne precautions. Which of the following would the nurse expect to see in the client's medical record?
- A. measles
- B. influenza
- C. Lyme disease
- D. herpes simplex
Correct Answer: A
Rationale: Measles requires airborne precautions due to its highly contagious nature via respiratory droplets, unlike the other conditions listed.
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The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics?
- A. Naloxone (Narcan)
- B. Ketorolac (Toradol)
- C. Acetylsalicylic acid (aspirin)
- D. Atropine sulfate (Atropine)
Correct Answer: A
Rationale: Naloxone reverses opioid overdose, critical for managing respiratory depression from morphine.
A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
- A. I keep having recurring nightmares.
- B. I have a headache and my vision is blurry.
- C. I feel like I'm watching myself from outside my body.
- D. I hear voices telling me what to do.
Correct Answer: C
Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.
The nurse is caring for a client following the removal of a central line catheter when the client suddenly develops dyspnea and complains of substernal chest pain. The client is noticeably confused and fearful. Based on the client's symptoms, the nurse should suspect which complication of central line use?
- A. Myocardial infarction
- B. Air embolus
- C. Intrathoracic bleeding
- D. Vagal response
Correct Answer: B
Rationale: Sudden dyspnea, chest pain, and confusion post-central line removal suggest an air embolus, a serious complication requiring immediate intervention.
The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?
- A. Adding fresh ground pepper to my food will improve the flavor.
- B. Meat should be thoroughly cooked to the proper temperature.
- C. Eating cheese and yogurt will prevent AIDS-related diarrhea.
- D. It is important to eat four to five servings of fresh fruits and vegetables a day.
Correct Answer: B
Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their weakened immune systems.
The nurse is caring for a client with epilepsy who is to receive Dilantin 100 mg IV push. The client has an IV of D51/2NS infusing at 100 mL/hr. When administering the Dilantin, the nurse should first:
- A. Obtain an ambu bag and put it at bedside
- B. Insert a 16 g IV catheter
- C. Flush the IV line with normal saline
- D. Premedicate with phenergan IV push
Correct Answer: C
Rationale: Dilantin is incompatible with dextrose solutions (D51/2NS), causing precipitation. Flushing with normal saline ensures compatibility and prevents complications.