Nokea
The nurse is inserting an intravenous line into the right arm and has identified a potential insertion site. Place the steps (indicated in Roman numerals) of venipuncture in the proper sequential order.
- A. Palpate vein.
- B. Cleanse skin
- C. Apply tourniquet.
- D. Perform venipuncture.
Correct Answer: C,A,B,D
Rationale: Venipuncture sequence: Apply tourniquet (III), palpate vein (I), cleanse skin (II), perform venipuncture (IV).
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Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?
- A. Antivirals
- B. Antibiotics
- C. Immunosuppressants
- D. Analgesics
Correct Answer: C
Rationale: Immunosuppressants, such as cyclosporine, prevent the immune system from forming antibodies against the transplanted heart.
The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is altered.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can diminish bladder sensation, increasing the risk of urinary retention, so hourly voiding is encouraged.
A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?
- A. activated charcoal per pharmacy
- B. start an IV with D5W to keep the vein open
- C. gastric lavage PRN
- D. acetylcysteine (Mucomyst) for age per pharmacy
Correct Answer: A
Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10 bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions.
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at contraction ends indicates severe distress, an ominous sign.
Which cephalic presentation is most common during delivery of a neonate?
- A. Vertex
- B. Face
- C. Military
- D. Brow
Correct Answer: A
Rationale: Vertex presentation (A), with the head flexed and occiput leading, is the most common (95%) during delivery.