Nokea
The nurse is preparing to start an I.V. infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to accomplish which of the following?
- A. Distend the veins.
- B. Stabilize the veins.
- C. Immobilize the arm.
- D. Occlude arterial circulation.
Correct Answer: A
Rationale: A tourniquet distends veins by restricting venous return, making them easier to access for I.V. insertion.
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A primary health care provider has written a prescription for a client diagnosed with diabetic gastroparesis to receive metoclopramide four times a day. The nurse schedules this medication to be given at which times?
- A. With each meal and at bedtime
- B. Thirty minutes before meals and at bedtime
- C. One hour after each meal and at bedtime
- D. Every 6 hours spaced evenly around the clock
Correct Answer: B
Rationale: Metoclopramide stimulates the motility of the upper gastrointestinal tract and is used to treat gastroparesis (nausea, vomiting, and persistent fullness after meals). The client should be taught to take this medication 30 minutes before meals and at bedtime. The before-meals administration allows the medication time to begin working before the client consumes food that requires digestion. The other options suggest information that is incorrect.
A client with no history of immunosuppressive disease has a Mantoux tuberculin skin test. The results indicate an area of induration that is 8 mm in size. How should the nurse interpret this result?
- A. Active tuberculosis
- B. A negative response
- C. A history of tuberculosis
- D. Past exposure to tuberculosis
Correct Answer: B
Rationale: Induration of 15 mm or more is considered positive for clients in low-risk groups. More than 5 mm of induration is considered a positive result for clients with known or suspected human immunodeficiency virus infection, persons with organ transplants, persons in close contact with a known case of tuberculosis, and those with a chest x-ray study suggestive of previous tuberculosis. More than 10 mm of induration is considered positive in all other high-risk groups, such as intravenous drug users.
A 7-year-old child with type 1 diabetes is admitted with diabetic ketoacidosis. Which intervention should the nurse prioritize?
- A. Administer insulin infusion
- B. Provide oral glucose
- C. Increase dietary carbohydrates
- D. Administer sodium bicarbonate
Correct Answer: A
Rationale: Insulin infusion is the priority in diabetic ketoacidosis to halt ketogenesis and correct hyperglycemia, addressing the underlying metabolic crisis.
The nurse should closely monitor the client with an open fracture for which of the following complications?
- A. Avascular necrosis.
- B. Compartment syndrome.
- C. Osteomyelitis.
- D. Fat embolism syndrome.
Correct Answer: C
Rationale: Open fractures have a high risk of osteomyelitis due to exposure to pathogens.
Which of the following characteristics should the nurse include in the teaching plan for a multiparous client after delivering a neonate diagnosed with trisomy 13?
- A. Webbed neck
- B. Small testes
- C. Congenital heart defects
- D. Polydactyly
Correct Answer: C
Rationale: Trisomy 13 is commonly associated with congenital heart defects. Webbed neck is more typical of Turner syndrome, and small testes or polydactyly are less specific to trisomy 13.