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The nurse is caring for a person who has a nasogastric tube attached to drainage. Which complaint by the client needs to be reported to the charge nurse?
- A. Dry mouth
- B. Weak muscles
- C. Sore throat
- D. Irritated nose
Correct Answer: C
Rationale: A sore throat may indicate nasogastric tube complications like erosion or infection, requiring evaluation. Dry mouth, weakness, or nasal irritation are expected.
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The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis.
- A. Which observation is expected in an 8-year-old girl with scoliosis?
- B. The girl’s thoracic area is asymmetrical.
- C. The girl walks with a waddling gait.
- D. The girl’s lower legs are edematous.
- E. The girl has a protruding sternum.
Correct Answer: A
Rationale: Scoliosis causes lateral spinal curvature, leading to thoracic asymmetry. Waddling gait is associated with hip issues, edema with circulatory problems, and a protruding sternum with pectus carinatum, none of which are typical of scoliosis.
The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST?
- A. After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen her/him sleeping on duty three times.
- B. I saw my coworker downtown after work. S/he was acting really strange, like s/he didn't even recognize me.
- C. I think my coworker is stealing narcotics because s/he is always acting euphoric and seems high.
- D. I am sure my coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms.
Correct Answer: A
Rationale: Objective observations, such as increased patient pain medication needs and sleeping on duty, provide verifiable evidence for investigation. Options B, C, and D are subjective or speculative, reducing their credibility.
The nurse is making patient assignments on the obstetrical unit.
Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrical unit from outpatient surgery?
- A. A patient at 16 weeks gestation admitted with hyperemesis receiving IV fluids.
- B. A patient at 26 weeks gestation in premature labor receiving terbutaline (Brethine).
- C. A patient at 32 weeks gestation with a placenta previa and ruptured membranes.
- D. A patient at 37 weeks gestation with pregnancy-induced hypertension and epigastric pain.
Correct Answer: A
Rationale: Strategy: LPN/LVN and 'pulled' RN receive stable patients with expected outcomes. (1) correct-monitor IV therapy, administer antiemetics and nutritional supplements (2) monitor patient's response to medication and the status of the fetus (3) prepare for delivery, closely monitor fetal response (4) indicates impending seizures, prepare for delivery
The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute.
- A. Which medication should the nurse expect to administer for a client with coupled PVCs greater than 10 per minute?
- B. Atropine sulfate (Atropine) IV.
- C. Isoproterenol (Isuprel) IV.
- D. Verapamil (Calan) IV.
- E. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent or coupled PVCs, as it suppresses ventricular arrhythmias that could lead to ventricular tachycardia. Atropine treats bradycardia, isoproterenol is used for heart block, and verapamil is a calcium-channel blocker for supraventricular arrhythmias.
The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
- A. Her diet is low in calories and high in iron.
- B. Her diet is low in calories and low in iron.
- C. Her diet is high in calories and low in iron.
- D. Her diet is high in calories and high in iron.
Correct Answer: C
Rationale: 900 × 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required