Nokea
The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should:
- A. Place tape completely around the extremity, with tape ends out of the client's vision
- B. Tell him that if he pulls out the IV, it will have to be restarted
- C. Slap the client's hand when he reaches toward the IV site
- D. Apply clove hitch restraints to the client's hands
Correct Answer: A
Rationale: Securing the IV with tape out of the client's vision minimizes tampering while avoiding restraints or inappropriate actions.
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The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?
- A. Uric acid of 5 mg/dL
- B. Hematocrit of 33%
- C. WBC 2000 per cubic millimeter
- D. Platelets 150,000 per cubic millimeter
Correct Answer: C
Rationale: A WBC of 2000 indicates leukopenia, a serious side effect of carbamazepine that increases infection risk.
A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. Bradycardia
- B. Decreased appetite
- C. Exophthalmos
- D. Weight gain
Correct Answer: C
Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
- A. The child is placed in a private room.
- B. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- D. The staff uses standard precautions.
Correct Answer: A
Rationale: contact precautions required for diapered or incontinent clients
A client is receiving oxygen therapy at 3 L/min per nasal cannula. Which of the following fraction of inspired oxygen (FiO2) measurements does the nurse expect that the client is receiving?
- A. 24%.
- B. 60%.
- C. 32%.
- D. 100%.
Correct Answer: C
Rationale: Nasal cannula at 3 L/min delivers approximately 32% FiO2 (C), as each liter increases FiO2 by about 4% above room air (21%). Other percentages (A, B, D) do not correspond to this flow rate.
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient’s left leg is externally rotated. The nurse should
- A. place a trochanter roll on the outer aspect of the thigh.
- B. perform resistive range of motion of the left leg.
- C. adduct and internally rotate the left leg.
- D. instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee