Nokea
The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.
- A. Falls asleep when the nurse is talking
- B. Frequently scratches from pruritus
- C. Has third emesis since taking medication
- D. Monitor shows occasional premature ventricular contractions
- E. Pulse oximetry reading is 92%
Correct Answer: A,C,D
Rationale: Falling asleep (A), vomiting (C), and premature ventricular contractions (D) indicate possible methadone overdose or toxicity, requiring extended monitoring. Pruritus (B) is a common side effect, and 92% oxygen saturation (E) is not critical.
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The nurse is reinforcing teaching about infant safety to a class of expectant parents. Which statement by a participant indicates a need for further instruction?
- A. I will allow my baby to sleep with a pacifier.
- B. I will dress my baby in a sleeping sack to prevent my baby from getting cold.
- C. I will make sure there is a firm mattress in the crib.
- D. I will only place one teddy bear in the crib to comfort my baby
Correct Answer: D
Rationale: Placing a teddy bear in the crib (D) increases suffocation risk, requiring further teaching. Pacifiers (A), sleep sacks (B), and firm mattresses (C) are safe.
The nurse is reinforcing teaching to the parents of a 6-month-old child who has been given a new prescription for a liquid iron supplement. Which statements by the parents indicate a need for further teaching? Select all that apply.
- A. Our child might become constipated while taking this medication.
- B. Our child's stools might become black and tarry.
- C. We can give the dose with milk to prevent gastric irritation.
- D. We will administer the dose into the back of our child's cheek.
- E. We will administer the dose with meals to increase absorption.
Correct Answer: C,E
Rationale: Giving iron with milk (C) reduces absorption and should be avoided. Administering with meals (E) also decreases absorption; iron is best given between meals with vitamin C. Statements A, B, and D are correct regarding side effects and administration.
Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
Which behavioral characteristic describes the domestic abuser?
- A. Alcoholic
- B. Over confident
- C. High tolerance for frustrations
- D. Low self-esteem
Correct Answer: D
Rationale: Low self-esteem. Batterers were usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, and have a great need to exercise control or power over their partners.
The nurse is caring for a client who is recovering from a cerebrovascular accident and is partially paralyzed on the right side. How should the nurse position the chair when getting the client out of bed?
- A. On the right side of the bed facing the foot of the bed
- B. On the right side of the bed facing the head of the bed
- C. On the left side of the bed facing the foot of the bed
- D. On the left side of the bed facing the head of the bed
Correct Answer: C
Rationale: Placing the chair on the left (unaffected) side facing the foot allows the client to pivot using their stronger side, facilitating safe transfer. Right-side placement or incorrect orientation hinders mobility.