Nokea
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
- A. Phlebostatic axis
- B. Point of maximal impulse
- C. Erb's point
- D. Tail of Spence
Correct Answer: A
Rationale: The phlebostatic axis (located at the fourth intercostal space mid-axillary line) is the standard reference point for zeroing the manometer to accurately measure central venous pressure. The other options are incorrect anatomical landmarks.
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After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
- A. Suicide
- B. Exacerbation of depressive symptoms
- C. Violence toward others
- D. Psychotic behavior
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery. To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.5 mg
- C. 0.05 mg
- D. 20 mg
Correct Answer: A
Rationale: 1 mg = 0.1 mL, then 0.5 mL X = 5 mg.
A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:
- A. Infection postoperatively
- B. Malignant hyperthermia
- C. Neuroleptic malignant syndrome
- D. Fever postoperatively
Correct Answer: B
Rationale: Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
- A. Prevent systemic infection
- B. Promote diuresis
- C. Decrease ammonia formation
- D. Acidify the small bowel
Correct Answer: C
Rationale: Neomycin is an antibiotic, but this is not the rationale for administering it to a client in hepatic coma. Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted.