Nokea
The nurse is caring for a client with a terminal illness who is expected to die during the shift. The nurse notes that the client has loud, wet respirations. Which of the following medications would effectively treat this finding?
- A. IM lorazepam
- B. sublingual atropine
- C. transdermal fentanyl
- D. sublingual ondansetron
Correct Answer: B
Rationale: Sublingual atropine (B) reduces salivary secretions, alleviating 'death rattle.' Lorazepam (A) is for anxiety, fentanyl (C) for pain, and ondansetron (D) for nausea.
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Which of the following organs is most likely to suffer permanent damage from shock?
- A. The heart
- B. The skin
- C. The brain
- D. The kidneys
Correct Answer: D
Rationale: The kidneys are highly susceptible to permanent damage from shock due to reduced perfusion, leading to acute kidney injury.
The nurse is changing a dressing. Which event indicates a break in sterile technique?
- A. The nurse opens the sterile dressing set by opening the first flap away from herself.
- B. The nurse turns around when answering a question asked by the client in the other bed.
- C. The nurse opens the dressing set on the overbed table.
- D. The nurse pours sterile saline into the container in the dressing set.
Correct Answer: B
Rationale: Turning around risks contaminating the sterile field by passing non-sterile areas over it. Opening flaps away, using the table, or pouring saline maintain sterility.
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
- A. Requiring the client to mop the floor
- B. Restricting the client's fluids throughout the day
- C. Withholding privileges each time the voiding occurs
- D. Toileting the client more frequently with supervision
Correct Answer: D
Rationale: Toileting the client more frequently with supervision. This approach addresses the physical need in a client with altered thought processes.
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
- A. Chest x-ray
- B. Blood culture
- C. Sputum culture
- D. PPD intradermal test
Correct Answer: D
Rationale: PPD intradermal test. The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.
The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?
- A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
- B. Explore the client's perception of how the surgery will positively affect their future
- C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
- D. Provide initial education about the procedure to the client immediately before it is performed
Correct Answer: A
Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.