Nokea
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:
- A. Place the client in Trendelenburg position
- B. Increase the infusion of normal saline
- C. Administer atropine intravenously
- D. Move the emergency cart to the bedside
Correct Answer: B
Rationale: Hypotension and unresponsiveness suggest hypovolemia or shock, so increasing the normal saline infusion is the initial action to restore volume.
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The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
- A. You may be electrocuted if you use water with this unit.'
- B. Please report skin irritation to the doctor.'
- C. The unit may be used anywhere on the body without fear of adverse reactions.'
- D. A cream should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Skin irritation is a common side effect of TENS; reporting it ensures timely management.
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
- A. Force fluids 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
- D. Cover the client's reproductive organs with an x-ray shield.
Correct Answer: B
Rationale: Voiding immediately before an IVP ensures the bladder is empty, improving visualization of the urinary tract.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. Fresh fruits and raw vegetables will make excellent betweenmeal snacks.
- D. I need to eliminate most sources of phenylalanine from my diet.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which must be avoided in phenylketonuria, indicating a need for further teaching.
The RN is making assignments on a 12-bed unit. Staff consists of one RN and two certified nursing assistants. Which client should be self-assigned?
- A. A client receiving decadron for emphysema
- B. A client with chest trauma and a new onset of hemoptysis
- C. A client with rib fractures and an O2 saturation of 93%
- D. A client 2 days post-operative lung surgery with a pulse oximetry of 92%
Correct Answer: B
Rationale: New-onset hemoptysis in a chest trauma client indicates potential serious complications (e.g., pulmonary hemorrhage) requiring RN assessment and intervention.
A student nurse is assigned to change a patient's dressing. The soiled bandage is saturated with bright red blood. How should the student nurse dispose of the bandage?
- A. in the hallway sharps container
- B. in a labeled or color-coded biohazard bag
- C. in the trash, but it must be double bagged
- D. in the trash can in the patient's room
Correct Answer: B
Rationale: Blood-saturated bandages are biohazardous and must be disposed of in a labeled biohazard bag to prevent infection transmission.