Nokea
The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation?
- A. Impaired mobility related to spasticity and fatigue.
- B. Risk for falls related to muscle weakness and sensory loss.
- C. Risk for seizures related to muscle tremors and loss of myelin.
- D. Impaired skin integrity related bowel and bladder incontinence.
Correct Answer: C
Rationale: Seizures are not a common manifestation of MS, as tremors and myelin loss do not directly cause seizures. The other diagnoses are valid, as MS commonly causes mobility issues, fall risks, and skin integrity concerns.
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A client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which of the following first?
- A. Place the forearm under a running stream of lukewarm water.
- B. Pat the injury with a dry washcloth.
- C. Wrap the entire forearm from the wrist to the elbow.
- D. Apply an ice pack for 20 minutes.
Correct Answer: C
Rationale: Bufferin (aspirin) impairs platelet function, prolonging bleeding. The first action is to apply pressure by wrapping the forearm to control bleeding. Running water or patting may not provide sufficient pressure, and ice is a secondary measure after bleeding is controlled.
The nurse is supervising a newly hired nurse administer prescribed medications via a double-lumen nasogastric tube (NGT) with an air vent. Which action by the newly hired nurse requires follow-up?
- A. irrigates the air vent before medication administration with water.
- B. contacts the pharmacy to obtain available medications in liquid form.
- C. flushes the NGT between medications with water.
- D. administers each medication separately through the NGT.
Correct Answer: A
Rationale: The air vent of an NGT should not be irrigated, as it is for air passage, not medication or fluid administration.
A male client underwent a spinal fusion yesterday. Which of the following nursing assessments should alert the nurse to the development of a possible complication?
- A. Lateral rotation of the head and neck.
- B. Clear yellowish fluid on the dressing.
- C. No need to stand in order to void.
- D. Nonproductive cough.
Correct Answer: B
Rationale: Clear yellowish fluid suggests a cerebrospinal fluid leak, a serious complication requiring immediate attention.
What is the purpose of sodium polystyrene sulfonate in acute renal failure?
- A. Lower blood pressure.
- B. Reduce serum potassium.
- C. Increase urine output.
- D. Correct acidosis.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate removes potassium from the body, treating hyperkalemia.
A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.