Nokea
The nurse is caring for an adult who had a cervical laminectomy this morning. After an uneventful stay in the postanesthesia care unit, the client is returned to the nursing care unit. How should the client be positioned immediately upon return?
- A. Supine
- B. Prone
- C. Semi-reclining
- D. Side-lying
Correct Answer: C
Rationale: Semi-reclining reduces neck strain and swelling post-cervical laminectomy, promoting comfort and healing. Supine or prone may increase pressure, and side-lying is less optimal.
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The nurse is administering digoxin to a 6-month-old infant. Which finding would cause the nurse to withhold the medication and notify the charge nurse or the physician?
- A. Apical heart rate of 85
- B. Appears lethargic
- C. Circumoral cyanosis
- D. Respiratory rate of 38
Correct Answer: A
Rationale: An apical heart rate below 100 in infants indicates bradycardia, a contraindication for digoxin due to toxicity risk, requiring withholding and reporting.
The infant of a diabetic mother has a blood glucose of 90 mg/dL and a serum calcium level of 7.0 mg/dL. The nurse should anticipate that which of the following medications would be administered IV?
- A. Insulin.
- B. Glucose.
- C. Phenobarbital.
- D. Calcium gluconate.
Correct Answer: D
Rationale: Hypocalcemia (7.0 mg/dL) in infants of diabetic mothers risks tetany; calcium gluconate is indicated. Options A, B, and C are inappropriate.
According to Erickson's stage of growth and development, the developmental task associated with middle childhood is:
- A. Trust
- B. Initiative
- C. Independence
- D. Industry
Correct Answer: D
Rationale: Middle childhood (ages 6-12) is associated with the developmental task of industry, where children focus on competence and achievement.
A 69-year-old woman has been receiving total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse would expect the patient to exhibit
- A. tinnitus, vertigo, blurred vision.
- B. fever, malaise, anorexia.
- C. diaphoresis, confusion, tachycardia.
- D. hyperpnea, flushed face, diarrhea.
Correct Answer: C
Rationale: insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination
Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
- A. Report any changes in hearing immediately because this is a common side effect.
- B. You should be taking vitamin B6 to prevent painful neuritis.
- C. If your big toes become painful, you must tell the physician.
- D. Your perspiration and urine may turn red-orange.
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.