Nokea
The nurse is caring for a client who is edentulous. Which of the following diet orders should the nurse request from the healthcare provider?
- A. a low sodium diet
- B. a mechanical soft diet
- C. a renal diet
- D. a high-fiber diet
Correct Answer: B
Rationale: A mechanical soft diet is appropriate for an edentulous client to ensure safe chewing and swallowing.
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The emergency department nurse is caring for a client with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The nurse knows that the first-line medication for this presentation is:
- A. Oral diphenhydramine
- B. Nebulized albuterol
- C. Oral prednisone
- D. Parenteral epinephrine
Correct Answer: D
Rationale: Anaphylaxis from a bee sting requires immediate parenteral epinephrine to reverse airway edema and respiratory distress.
The following scenario applies to the next 1 items
The emergency department nurse is caring for a 22-year-old with altered mental status
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Admission Notes
2330 – 22-year-old male client arrived at the emergency department (ED) with friends who were at a party and was observed snorting a white powder and started acting erratically.
The client is hyper-alert, agitated, and only oriented to place on assessment. The client started shouting at staff during the assessment and struck a nurse with his fist. The primary healthcare provider (PHCP) was immediately notified of this incident.
Vital Signs
• Temperature 98.0o F (37o C)
• Pulse 110/minute
• Respirations 16/minute
• Blood Pressure 155/96 mm Hg
• O2 saturation 96% on room air
Complete the following sentences from the list of options.. Based on the client assessment, the client is likely intoxicated with ___ the nurse should immediately ___ based on the client's ___
- A. heroin
- B. cocaine
- C. restrain the client
- D. obtain a urine drug screen
- E. blood pressure
- F. physical violence
Correct Answer: B, C, F
Rationale: The client's agitation, hyper-alertness, and violence suggest cocaine intoxication. Immediate restraint ensures safety, and violence justifies this action.
The nurse receives a prescription to administer dopamine at 5 mcg/kg/min. The nurse has a bag labeled with dopamine 200 mg in 250 mL of D5W on hand. The client weighs 81.81 kg (179.98 lbs). How many mL/hr will the nurse administer?
Correct Answer: 31 mL/hr
Rationale: Calculation: 81.81 kg x 5 mcg/kg/min = 409.05 mcg/min x 60 = 24,543 mcg/hr = 24.543 mg/hr. Dopamine: 200 mg/250 mL = 0.8 mg/mL. 24.543 / 0.8 = 30.68 mL/hr, rounded to 31 mL/hr.
The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate?
- A. Stop! You will kill your baby.
- B. That is a nice, tight swaddle. It will help soothe your new baby.
- C. May I help you? We must be careful with the baby's intestines since we do not want the swaddle to push them back inside.
- D. Swaddling is not allowed for these babies; please stop.
Correct Answer: C
Rationale: This statement educates the parent gently, explaining the risk to the omphalocele without alarming them.
The following scenario applies to the next 1 items
The nurse is caring for a client in active labor
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Nurses’ Note
23-year-old primipara at 39 gestational weeks was admitted for induction via oxytocin. Currently, she is 100% effaced and 10 cm dilated. An internal fetal spiral electrode and intrauterine pressure catheter were placed. Uterine contractions are now 2 to 2.5 minutes apart, 70 to 90 seconds in duration. The fetal heart tracing showed decreased fetal heart rate following uterine contraction. This pattern was present in more than 50% of the uterine contractions.
Medications
Oxytocin via continuous infusion
Complete the following sentence from the list of options. Based on the fetal heart rate tracing, the client is experiencing ___ that is caused by ___
- A. late decelerations
- B. early decelerations
- C. variable decelerations
- D. reduced blood flow to the placenta
- E. umbilical cord compression
- F. fetal head compression
Correct Answer: A, D
Rationale: Late decelerations, caused by reduced placental blood flow, indicate fetal hypoxia and require intervention.