Nokea
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content.
- B. Place the patient in a left-lying position.
- C. Administer feeding with 50% Dextrose.
- D. Ensure that the feeding solution has been warmed in a microwave for two minutes.
Correct Answer: A
Rationale: Verifying nasogastric tube placement by aspirating stomach contents (and checking pH) is critical to prevent aspiration. Left-lying position is incorrect, 50% dextrose is inappropriate, and microwaving can cause burns or nutrient degradation.
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The physician has prescribed Zyvox (linezolid) for a patient with VRE. The concurrent use of which medication may result in serotonin syndrome?
- A. Nexium (esomeprazole)
- B. Zoloft (sertraline)
- C. Lipitor (atorvastatin)
- D. Zyrtec (cetirizine)
Correct Answer: B
Rationale: Linezolid, a monoamine oxidase inhibitor, can cause serotonin syndrome when combined with SSRIs like Zoloft (sertraline), due to excessive serotonin accumulation. Nexium, Lipitor, and Zyrtec do not interact in this way.
A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:
- A. The blood pressure
- B. The temperature
- C. The urinary output
- D. The specific gravity of the urine
Correct Answer: A
Rationale: Adrenalectomy can disrupt cortisol and aldosterone production leading to blood pressure instability (e.g. hypotension from adrenal insufficiency). Monitoring blood pressure is critical to detect and manage these changes promptly.
On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
- A. Normal involution
- B. A full bladder
- C. An infection pain
- D. A hemorrhage
Correct Answer: B
Rationale: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.
As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
- A. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
- B. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
- C. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
- D. Do not leave the victim alone to collect her thoughts.
Correct Answer: A
Rationale: Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. This action is of lesser importance at this time. Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. Once the victim enters the emergency room, it is important not to leave her alone.
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Neosporin sulfate
- B. Mafenide acetate
- C. Silver sulfadiazine
- D. Povidone-iodine
Correct Answer: B
Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.