Nokea
The nurse is caring for an adult who had a cervical laminectomy this morning. In addition to routine vital signs, what should the nurse assess because of the location of the surgery?
- A. Pedal pulses
- B. Hand grasps
- C. Radial pulse
- D. Urine output
Correct Answer: B
Rationale: Cervical laminectomy affects the cervical spine, which innervates upper extremities; assessing hand grasps evaluates neurological function. Pedal pulses, radial pulse, and urine output are unrelated.
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A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused.
- A. What is the most appropriate response by the nurse to a young adult patient exhibiting attention-seeking behavior?
- B. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- C. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- D. Ignore the patient when she exhibits attention-seeking behavior.
- E. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: Rewarding non-attention-seeking behaviors with unsolicited attention reinforces positive behavior. Ignoring the patient or rotating staff does not address the behavior constructively, and assigning one staff member reduces consistency in approach.
A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders?
- A. Theophylline (Somophyllin) 0.7 mg/kg/hr IV.
- B. Tetracycline hydrochloride (Sumycin) 250 mg IM qd.
- C. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid.
- D. Propranolol hydrochloride (Inderal) 40 mg PO bid.
Correct Answer: D
Rationale: Propranolol, a non-selective beta-blocker, can cause bronchoconstriction, worsening COPD. Options A, B, and C are appropriate: theophylline bronchodilates, tetracycline treats infections, and ipratropium reduces bronchospasm.
An adult had major abdominal surgery this morning under general anesthesia. When the client arrives in the recovery room, she is very lethargic and restless. Her BP is 150/98; pulse is 110 and irregular; and respirations are 30 breaths per minute and shallow. Postoperative orders include meperidine (Demerol) 75 mg IM for operative site pain; reinforce dressings PRN; oxygen at 6 L/min PRN; irrigate nasogastric tube every 2 hours and PRN; IV 2500 cc D5W in 24 hours. What should the nurse do next?
- A. Carefully inspect the dressings for any drainage
- B. Irrigate the nasogastric tube
- C. Administer meperidine (Demerol) as ordered
- D. Administer oxygen
Correct Answer: D
Rationale: Tachypnea, tachycardia, and restlessness suggest hypoxia. Administering oxygen at 6 L/min addresses this critical need. Dressings, nasogastric irrigation, and pain medication are secondary to stabilizing oxygenation.
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
- A. When a family member offers information about their loved one
- B. When the client threatens self-harm and harm to others
- C. When the provider requests a copy of the client's history
- D. When a visitor insists that the visitor has been given permission by the client
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.
An 85-year-old client with diverticulitis has been vomiting and febrile for 12 hours. Where is the best location to assess skin turgor on this client?
- A. Dorsal hand
- B. Feet
- C. Back of the arm
- D. Sternum
Correct Answer: D
Rationale: This is the best area to check in the elderly due to loss of skin elasticity that occurs with aging. Answers A, B, and C are all influenced by loss of elasticity more than the sternum, so they are incorrect.