Nokea
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.
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An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
- A. lamivudine/zidovudine (Combivir).
- B. famciclovir (Famvir).
- C. ciprofloxacin (Cipro).
- D. voriconazole (Vfend)
Correct Answer: D
Rationale: Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
The physician has prescribed imipramine (ToFranil) for a client with depression. The nurse should continue to monitor the client's affect because the maximal effects of tricyclic antidepressant medication do not occur for:
- A. 48-72 hours
- B. 5-7 days
- C. 2-4 weeks
- D. 3-6 months
Correct Answer: C
Rationale: Tricyclic antidepressants like imipramine take 2-4 weeks to reach maximal therapeutic effect, requiring ongoing monitoring of the client's mood.
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
- A. Fracture of the clavicle
- B. Periorbital bruising
- C. Retinal hemorrhages
- D. Fracture of the humerus
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?
- A. Increase the irrigation flow rate.
- B. Notify the physician.
- C. Administer a diuretic as ordered.
- D. Stop the irrigation and assess the catheter.
Correct Answer: B
Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification
The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
- A. Cheyne-Stokes respirations
- B. Kussmaul respirations
- C. Biot respirations
- D. Diaphragmatic respirations
Correct Answer: A
Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.