Nokea
The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time?
- A. Early in the morning and before lunch
- B. Before meals and at the end of the day
- C. Early in the morning and late in the day
- D. Following exertion and at the end of the day
Correct Answer: D
Rationale: The client with myasthenia gravis has weakness after periods of exertion and near the end of the day. Medication therapy should assist in alleviating the weakness. The medication regimen may not be optimal if the client continues to experience fatigue. The nurse also works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client is also instructed to take medication as prescribed.
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A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
- A. The neonate will be suctioned.
- B. The neonate will be dried and stimulated.
- C. The neonate will be given oxygen.
- D. The neonate's umbilical cord will be cut.
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
You are going to perform gastric lavage for your adult client who was accidentally poisoned. How many mLs of irrigating solution would you instill after each suctioning?
- A. 100 mLs
- B. 250 mLs
- C. 400 mLs
- D. 500 mLs
Correct Answer: B
Rationale: Gastric lavage typically involves instilling 200-300 mL of solution (commonly 250 mL) per cycle to effectively wash out the stomach contents.
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg). The nurse should monitor the client for which of the following adverse effects?
- A. Bradycardia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
- A. Flexing the client's neck
- B. Leaving dentures in place
- C. Suctioning the client's mouth only if prescribed
- D. Inserting the airway with the tip pointed upward
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply.
- A. Olfactory Cranial Nerve: The sensory nerve that transmits the sense of smell to the olfactory foramina of the nose
- B. Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain.
- C. Oculomotor Cranial Nerve: This motor and sensory nerve controls eye movements and visual acuity.
- D. Trochlear Cranial Nerve: This motor nerve innervates eye ball movement and the superior oblique muscle of the eyes.
- E. Abducens Cranial Nerve: This motor nerve innervates and controls the abduction of the eye using the lateral rectus muscle.
- F. Facial Cranial Nerve: This motor nerve controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue.
- G. Glossopharyngeal Cranial Nerve: This sensory nerve This nerve gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands
Correct Answer: A,B,D,E,F
Rationale: Options A, B, D, E, and F are correct. The olfactory nerve (I) is sensory for smell, the optic nerve (II) is sensory for vision, the trochlear nerve (IV) is motor for the superior oblique muscle, the abducens nerve (VI) is motor for the lateral rectus muscle, and the facial nerve (VII) is both motor and sensory, controlling facial movements and taste from the anterior tongue. Option C is incorrect because the oculomotor nerve (III) does not control visual acuity, and option G is incorrect because the glossopharyngeal nerve (IX) is both sensory and motor, not purely sensory.