Nokea
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
- A. Pallor
- B. Increased temperature
- C. Dyspnea
- D. Involuntary muscle spasms
Correct Answer: C
Rationale: Dyspnea. Clients having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
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A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
- A. Change in libido, breast enlargement
- B. Sore throat, fever
- C. Abdominal pain, nausea, diarrhea
- D. Dyspnea, nasal congestion
Correct Answer: B
Rationale: A sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine).
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the dorsal gluteal site
- C. call to get a smaller volume ordered
- D. check with pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: administer the medication in 2 separate injections. Intramuscular injections should not exceed a volume of 1 ml for small children. Medication doses exceeding this volume should be split into 2 separate injections of 1.0 ml each. In adults the maximum intramuscular injection volume is 5 ml per site.
Which of these findings would the nurse more closely associate with anemia in a 10 month-old infant?
- A. hemoglobin level of 12 g/dL
- B. pale mucosa of the eyelids and lips
- C. hypoactivity
- D. a heart rate between 80 and 130
Correct Answer: B
Rationale: pale mucosa of the eyelids and lips. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?
- A. light, pink urine
- B. occasional suprapubic cramping
- C. minimal drainage into the urinary collection bag
- D. reports of the feeling of pulling on the urinary catheter
Correct Answer: C
Rationale: Options A, B, and D are expected complaints after this procedure. Option C needs to be reported immediately since minimal urinary drainage puts the client at risk for bladder rupture.
The nurse is preparing to care for the client diagnosed with tuberculosis who has been coughing up blood. Which illustration best shows the PPE that the nurse should plan to wear?
- A. ppe_1.PNG
- B. ppe_2.PNG
- C. ppe_3.PNG
- D. ppe_4.PNG
Correct Answer: D
Rationale: D: N95 respirator for airborne precautions and a face shield for blood exposure are appropriate. Other options lack adequate respiratory or splash protection.