Nokea
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.
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The nurse is caring for a client with a history of schizophrenia. Which medication is most likely to be prescribed?
- A. Fluoxetine (Prozac)
- B. Risperidone (Risperdal)
- C. Clonazepam (Klonopin)
- D. Bupropion (Wellbutrin)
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to treat schizophrenia by managing hallucinations and delusions. Fluoxetine and bupropion are antidepressants, and clonazepam is for anxiety.
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which intervention is most appropriate to prevent toxicity?
- A. Monitor respiratory rate
- B. Assess deep tendon reflexes
- C. Measure urine output
- D. All of the above
Correct Answer: D
Rationale: Magnesium sulfate toxicity can cause respiratory depression loss of reflexes and reduced urine output. Monitoring respiratory rate reflexes and urine output is essential to detect toxicity early and ensure patient safety.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
- A. Libel
- B. Slander
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery. To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.