Nokea
The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask?
- A. Did you have anything to eat or drink before you came in today?
- B. Have you had any headaches since your last treatment?
- C. Who came with you to the hospital today?
- D. Have you had much memory loss since you began your treatments?
Correct Answer: A
Rationale: client given general anesthesia for ECT; NPO after midnight
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Which of the following nursing approaches would be MOST appropriate to use while administering an oral medication to a four-month-old?
- A. Place the medication in 45 cc of formula.
- B. Place the medication in an empty nipple and allow the infant to suck.
- C. Place the medication in a full bottle of formula.
- D. Administer the medication using a plastic syringe, with the infant in the reclining position.
Correct Answer: B
Rationale: is a convenient method for administering medications to an infant
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which of the following instructions should the nurse include?
- A. Use oxygen only when feeling short of breath.
- B. Store oxygen tanks near an open flame.
- C. Avoid smoking while using oxygen.
- D. Use a humidifier with oxygen at high flow rates.
Correct Answer: C
Rationale: Smoking near oxygen risks fire, a critical safety concern. Options A, B, and D are incorrect or unsafe.
The mother of a seven-year-old child is dying.
The nurse should anticipate that the seven-year-old child would have which of the following concepts of death?
- A. Death is punishment for his/her actions.
- B. Death is inevitable and irreversible.
- C. Death is temporary and gradual.
- D. Death as a concept based on past experience.
Correct Answer: A
Rationale: Strategy: Remember growth and development. (1) correct-seven-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child's concept of death (4) is an adolescent's concept of death
The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus?
- A. A 19-year-old four days postpartum with an obstetrical history of placenta previa.
- B. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago.
- C. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily.
- D. A 22-year-old leukemic client with a platelet count of 120,000/mm³ and a hemoglobin level of 9.0 g.
Correct Answer: B
Rationale: obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli
A client is admitted to the unit with pregnancy-induced hypertension (PIH).
Which of the following actions is the priority nursing action?
- A. Start an IV.
- B. Obtain the vital signs.
- C. Administer magnesium sulfate.
- D. Notify the lab to draw blood.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation, not a priority action (2) correct-assessment, important to do a baseline assessment in order to successfully evaluate the treatment (3) implementation, not a priority action (4) implementation, not a priority action