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The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What should the nurse monitor when considering the actions and the effects of this medication?
- A. Urinary pH
- B. Radial pulse
- C. Temperature
- D. Blood pressure
Correct Answer: D
Rationale: Lidocaine hydrochloride is an antidysrhythmic medication used to treat ventricular dysrhythmias. It can cause hypotension as a side effect, so monitoring blood pressure is critical to assess for adverse effects and ensure client safety. Urinary pH, radial pulse, and temperature are not directly related to the primary actions or adverse effects of lidocaine.
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Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
- A. Practice meticulous hand hygiene.
- B. Maintain the head of the bed elevation at 10 degrees.
- C. Perform suctioning of oral cavity secretions every 4 hours.
- D. Have the respiratory therapist change the ventilator circuit tubing every 4 hours.
Correct Answer: A
Rationale: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.
A parent reports that her child has developed a bloody nose. Which action should the nurse instruct the parent to take to control the bleeding?
- A. Pinch the nostrils for 5 minutes and then recheck for bleeding.
- B. Maintain the child in a sitting position with the head tilted backward.
- C. Lay the child down with a pillow tucked under the neck and stay with the child to keep the child calm.
- D. Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes.
Correct Answer: D
Rationale: The child should be positioned erect, sitting with head tilted forward to avoid blood dripping posteriorly to the pharynx. The soft part of the nose should be tightly pinched against the center wall for 10 minutes, and the parent should be instructed that this pinch should be timed by a clock, not estimated. The parent should be told not to release pressure for 10 minutes. The child is encouraged to remain calm and quiet and to breathe through the mouth.
A client with a history of migraine headaches is prescribed sumatriptan (Imitrex). The nurse should instruct the client to:
- A. Take the medication at the onset of a migraine.
- B. Take the medication daily to prevent migraines.
- C. Avoid taking the medication with food.
- D. Stop the medication if nausea occurs.
Correct Answer: A
Rationale: Sumatriptan is most effective when taken at the onset of a migraine to abort the attack.
Your client is experiencing general malaise. Which stage of infection is this client in?
- A. The incubation stage
- B. The illness stage
- C. The prodromal stage
- D. The convalescence stage
Correct Answer: B
Rationale: General malaise is characteristic of the illness stage, where symptoms of the infection are most prominent.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.