Nokea
The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?
- A. Administer an ordered antiemetic
- B. Obtain an ice bag and apply to the client's throat
- C. Turn the client to one side
- D. Notify the physician
Correct Answer: C
Rationale: Turning the client to one side prevents aspiration, a risk in CVA patients with nausea due to impaired swallowing or consciousness. This is the priority before other actions.
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The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.
The nurse is caring for a client receiving IV vancomycin. The trough level is 14 mcg/mL. The next dose is now due. What is the correct response by the nurse?
- A. give the next dose as ordered
- B. wait 2 hours and redraw the trough
- C. wait 30 minutes and redraw the trough
- D. hold the dose and notify the health care provider
Correct Answer: A
Rationale: A vancomycin trough of 14 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the next dose can be given as ordered.
The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?
- A. The client's blood pressure is 130/86.
- B. The client is unable to concentrate.
- C. The client's pupils are dilated.
- D. The client grimaces during care.
Correct Answer: D
Rationale: Grimacing during care indicates pain, prompting the nurse to administer an analgesic.
A client confides in the nurse that a close friend recently died from pancreatic cancer. The client asks what the risk factors are for pancreatic cancer. The nurse should respond with
- A. Being a female of Asian descent is linked to an increased risk of pancreatic cancer.'
- B. Drinking two or fewer alcoholic beverages per week is linked to an increased risk of pancreatic cancer.'
- C. Past history of acute pancreatitis before age 20 is linked to an increased risk of pancreatic cancer.'
- D. Cigarette smoking is linked to an increased risk for pancreatic cancer.'
Correct Answer: D
Rationale: Cigarette smoking is a well-established risk factor for pancreatic cancer, increasing risk through carcinogenic exposure.
Which of the following are true statements regarding peripherally inserted central catheter (PICC) lines? Select all that apply.
- A. requires sterile technique during insertion
- B. can be inserted by any LPN or RN
- C. lower risk of infection compared to other central lines
- D. increased risk of pneumothorax
- E. can be inserted at the patient bedside
Correct Answer: A,C,E
Rationale: PICC lines require sterile technique, have a lower infection risk than other central lines, and can be inserted at the bedside. Only specially trained RNs (not any LPN/RN) can insert them, and pneumothorax risk is minimal.