Nokea
The nurse is teaching a class on substance use disorders. It would be correct for the nurse to characterize physical dependence as
- A. obsessive desire for the euphoric effects of a drug
- B. a need for a drug to avoid physical withdrawal symptoms
- C. severe effects that may be life-threatening
- D. unpleasant symptoms related to the absence of a drug
Correct Answer: B
Rationale: Physical dependence is defined as needing a drug to avoid withdrawal symptoms.
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The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions?
- A. Rubeola
- B. Psoriasis
- C. Pediculosis
- D. Rubella
- E. Scabies
- F. Clostridium difficile
Correct Answer: C, E, F
Rationale: Pediculosis, scabies, and Clostridium difficile require contact precautions due to direct contact transmission.
The following scenario applies to the next 1 items
The nurse is caring for a client in active labor
Item 1 of 1
Nurses’ Note
23-year-old primipara at 39 gestational weeks was admitted for induction via oxytocin. Currently, she is 100% effaced and 10 cm dilated. An internal fetal spiral electrode and intrauterine pressure catheter were placed. Uterine contractions are now 2 to 2.5 minutes apart, 70 to 90 seconds in duration. The fetal heart tracing showed decreased fetal heart rate following uterine contraction. This pattern was present in more than 50% of the uterine contractions.
Medications
Oxytocin via continuous infusion
Complete the following sentence from the list of options. Based on the fetal heart rate tracing, the client is experiencing ___ that is caused by ___
- A. late decelerations
- B. early decelerations
- C. variable decelerations
- D. reduced blood flow to the placenta
- E. umbilical cord compression
- F. fetal head compression
Correct Answer: A, D
Rationale: Late decelerations, caused by reduced placental blood flow, indicate fetal hypoxia and require intervention.
The nurse is caring for a client who is edentulous. Which of the following diet orders should the nurse request from the healthcare provider?
- A. a low sodium diet
- B. a mechanical soft diet
- C. a renal diet
- D. a high-fiber diet
Correct Answer: B
Rationale: A mechanical soft diet is appropriate for an edentulous client to ensure safe chewing and swallowing.
The nurse is caring for a child diagnosed with Tetralogy of Fallot. The client has had multiple hypercyanotic episodes (tet spells). The nurse anticipates that the physician will prescribe
- A. morphine sulfate
- B. adenosine
- C. diltiazem
- D. atropine sulfate
Correct Answer: A
Rationale: Morphine sulfate is used to manage tet spells by reducing oxygen demand and relaxing the child.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 2 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
The nurse is most concerned about the client developing ___ due to ___ and ___
- A. ischemic stroke
- B. intra-abdominal hemorrhage
- C. neurological assessment
- D. anticoagulant use
- E. pulse
- F. anticoagulant use
- G. atrial fibrillation
Correct Answer: A, D, G
Rationale: Warfarin use and atrial fibrillation increase the risk of ischemic stroke, especially with a history of trauma and neurological symptoms.