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The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate?
- A. Give the next dose of chloral hydrate early.
- B. Contact the physician to obtain new orders.
- C. Instruct the toddler's mother to read to him.
- D. Take the toddler out of traction for 30 minutes.
Correct Answer: B
Rationale: Irritability and restlessness suggest a paradoxical reaction to chloral hydrate, requiring physician notification for medication adjustment. Options A, C, and D are unsafe or ineffective.
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Twenty-four hours after abdominal surgery.
Which of the following plans would be a nursing priority to prevent complications of flatulence?
- A. Encourage the client to drink carbonated beverages daily.
- B. Instruct the client to turn from side to side.
- C. Encourage the client to do leg exercises in bed.
- D. Assist the client to walk in the hall every 2 hours.
Correct Answer: D
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) increasing carbonated beverages will increase flatus (2) will prevent postoperative complications, but not flatulence (3) does not address flatulence (4) correct-will increase peristalsis, decreasing the development of flatus
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which of the following instructions should the nurse include?
- A. Use oxygen only when feeling short of breath.
- B. Store oxygen tanks near an open flame.
- C. Avoid smoking while using oxygen.
- D. Use a humidifier with oxygen at high flow rates.
Correct Answer: C
Rationale: Smoking near oxygen risks fire, a critical safety concern. Options A, B, and D are incorrect or unsafe.
A client reports that he has been vomiting for three days, has a low-grade temperature, and feels lethargic. Which of the following nursing actions is MOST appropriate in evaluating for fluid volume deficit?
- A. Obtain a urinalysis for casts and specific gravity.
- B. Determine client's weight and assess gain or loss.
- C. Ask client to provide a 24-hour intake and output record.
- D. Determine the quality of the client's skin turgor.
Correct Answer: B
Rationale: daily weight is the best way to evaluate for fluid volume deficit
The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with food.
- B. I should check my pulse before taking this medication.
- C. I should report dizziness to my doctor.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping carvedilol when feeling better is incorrect, as heart failure requires lifelong treatment to manage symptoms and prevent progression. Options A, B, and C are correct: food reduces GI upset, pulse monitoring detects bradycardia, and dizziness may indicate hypotension.
A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
- A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
- B. I'll use a tongue blade to collect a small amount of stool in a clean container.
- C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
- D. I'll ask the patient if he has ingested any red meat recently.
Correct Answer: C
Rationale: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading