Nokea
The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which of the following actions should the nurse take next?
- A. Press the emergency alarm to call the resuscitation team.
- B. Cover the abdominal organs with sterile dressings moistened with sterile normal saline.
- C. Have all visitors and family leave the room.
- D. Call the surgeon to come to the client's room immediately.
Correct Answer: B
Rationale: Covering exposed intestines with sterile, moist dressings prevents infection and drying of tissues, stabilizing the situation until surgical intervention. This is the immediate priority.
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Which of the following describes decerebrate posturing?
- A. Internal rotation and adduction of arms with the excess, wrists, and fingers.
- B. Back hunched with the position of all four extremities with supination of arms and plantar flexion of feet.
- C. Supination of arms, dorsiflexion of the feet.
- D. Back arched, rigid extension of all four extremities.
Correct Answer: D
Rationale: Decerebrate posturing involves rigid extension of all extremities with arched back, indicating severe brain stem dysfunction. The other options describe decorticate posturing or incorrect combinations of movements.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?
- A. Determining the client's knowledge level about cholesterol.
- B. Asking the client to name foods that are high in fat, cholesterol, and salt.
- C. Explaining the importance of complying with the diet.
- D. Assessing the client's and family's typical food preferences.
Correct Answer: D
Rationale: Assessing food preferences ensures the dietary plan is tailored and practical.
The nurse has attended a continuing education conference regarding medication administration and meal times. Which statement, if made by the nurse, would indicate correct understanding?
- A. Proton pump inhibitors (PPls) should be given as the client eats their breakfast.
- B. Glucocorticoids should be given on an empty stomach to prevent gastrointestinal irritation.
- C. Rapid-acting insulins should be administered approximately 5-10 minutes before meals
- D. Levodopa-Carbidopa should be administered with a high-protein snack to enhance its absorption.
Correct Answer: C
Rationale: Rapid-acting insulins are administered 5-10 minutes before meals to match glucose spikes.
Which intervention is appropriate for a client on hemodialysis?
- A. Check fistula for a thrill.
- B. Restrict all fluids.
- C. Administer heparin post-dialysis.
- D. Encourage high-protein diet.
Correct Answer: A
Rationale: Checking for a thrill ensures fistula patency for dialysis.