Nokea
The nurse is caring for a client with a suspected anaphylactic reaction. Which assessment finding confirms this diagnosis?
- A. Wheezing and hypotension
- B. Fever and rash
- C. Bradycardia and hypertension
- D. Nausea and diarrhea
Correct Answer: A
Rationale: Wheezing and hypotension are hallmark signs of anaphylaxis, indicating airway constriction and systemic vasodilation requiring immediate intervention.
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A primary health care provider has written a prescription for a client diagnosed with diabetic gastroparesis to receive metoclopramide four times a day. The nurse schedules this medication to be given at which times?
- A. With each meal and at bedtime
- B. Thirty minutes before meals and at bedtime
- C. One hour after each meal and at bedtime
- D. Every 6 hours spaced evenly around the clock
Correct Answer: B
Rationale: Metoclopramide stimulates the motility of the upper gastrointestinal tract and is used to treat gastroparesis (nausea, vomiting, and persistent fullness after meals). The client should be taught to take this medication 30 minutes before meals and at bedtime. The before-meals administration allows the medication time to begin working before the client consumes food that requires digestion. The other options suggest information that is incorrect.
A client with a fractured femur is placed in skeletal traction. The nurse should assess the client for which of the following complications?
- A. Pressure ulcers.
- B. Deep vein thrombosis.
- C. Hypovolemia.
- D. Infection at the pin sites.
Correct Answer: B,D
Rationale: Skeletal traction increases the risk of deep vein thrombosis due to immobility and infection at pin sites due to skin penetration.
A client has an anaphylactic reaction to penicillin that results in respiratory distress. Which of the following medications should the nurse anticipate administering?
- A. Dopamine (Intropin).
- B. Epinephrine.
- C. Albuterol (Proventil).
- D. Diphenhydramine (Benadryl).
Correct Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis, as it rapidly reverses respiratory distress and other symptoms by constricting blood vessels and relaxing airways.
Which of these case management methods employs the intrinsic use of multidisciplinary plans of care that are based on the client's current condition, and reflect interventions and expected outcomes within a pre-established time line?
- A. The Case Manager Model
- B. The ProACT Model
- C. The Collaborative Practice Model
- D. The Triad Model of Case Management
Correct Answer: D
Rationale: The Triad Model of Case Management uses multidisciplinary plans of care based on the client's current condition, with interventions and expected outcomes within a pre-established timeline, involving collaboration among nursing, social work, and utilization review teams.
Which of the following interventions is recommended protocol for all clients who are at risk for pressure sore development?
- A. Identify clients at risk upon admission to the health care facility.
- B. Place at-risk clients on an every-2-hour turning schedule.
- C. Automatically place clients in specialty beds.
- D. Provide at-risk clients with a high-protein, high-carbohydrate diet.
Correct Answer: B
Rationale: Regular repositioning every 2 hours prevents prolonged pressure on skin, reducing the risk of pressure sores in at-risk clients.