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The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what should be the nurse's next priority?
- A. Monitor for sharp epigastric pain.
- B. Give warm gargles for sore throat.
- C. Check for a return of the gag reflex.
- D. Monitor for complaints of heartburn.
Correct Answer: C
Rationale: The nurse places highest priority on assessing for the return of the gag reflex, which is part of maintaining the client's airway. The nurse should also monitor the client for sharp pain (may indicate a potential complication) and heartburn. The client would receive warm gargles, but this cannot be done until the gag reflex has returned.
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A client with a history of schizophrenia is prescribed quetiapine (Seroquel). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A, D
Rationale: Quetiapine can cause weight gain and hypotension.
The nurse should consider which of the following principles when developing a plan of care to manage a client's pain from cancer?
- A. Individualize the pain medication regimen for the client.
- B. Select medications that are least likely to lead to addiction.
- C. Administer pain medication as soon as the client requests it.
- D. Change pain medications periodically to avoid drug tolerance.
Correct Answer: A
Rationale: Individualizing the regimen ensures effective pain control tailored to the client's needs, considering cancer pain's variable nature.
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
- A. Watching television with his roommate.
- B. Coloring picture books with his brother.
- C. Keeping up with his school work.
- D. Building a bird house.
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
Which site or technique would you expect to use to administer ferrous sulfate?
- A. A subcutaneous injection site
- B. The PQRST technique
- C. The Z track technique
- D. The sublingual site
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). Which observation in the PVCs would indicate to the nurse that this therapy is ineffective?
- A. Occur in pairs
- B. Be unifocal in appearance
- C. Be fewer than 6 per minute
- D. Fall after the end of the T wave
Correct Answer: A
Rationale: PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave.