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The nurse is to administer an antibiotic to a client with burns now, but there is no medication in the client's medication box. What should the nurse do first?
- A. Inform the unit's shift coordinator.
- B. Contact the client's physician.
- C. Call the pharmacy department.
- D. Borrow the medication from another client.
Correct Answer: C
Rationale: Calling the pharmacy ensures timely delivery of the correct medication, maintaining safety and adherence to protocol. Borrowing medication is unsafe and unethical.
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The client asks the nurse, 'Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?' The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on:
- A. The need to remove as much of the leg as possible
- B. The adequacy of the blood supply to the tissues
- C. The ease with which a prosthesis can be fitted
- D. The client's ability to walk with a prosthesis
Correct Answer: B
Rationale: The level of amputation depends primarily on the adequacy of blood supply to the tissues, as determined intraoperatively. Sufficient perfusion is necessary for healing and preventing further necrosis. Removing excess tissue, prosthesis fitting, or walking ability are secondary considerations.
Which of the following are expected outcomes for a client with pulmonary disease?
- A. A relatively matched ventilation-to-perfusion ratio.
- B. A low ventilation-to-perfusion ratio.
- C. A high ventilation-to-perfusion ratio.
- D. An equal PaO2 and PaCO2 ratio.
Correct Answer: A
Rationale: A matched ventilation-to-perfusion ratio is the goal in pulmonary disease for efficient gas exchange. Low or high ratios indicate mismatch. Equal PaO2 and PaCO2 is not a standard outcome.
The nurse notes that the daily white blood cell (WBC) count in a client with aplastic anemia has dropped overnight from 3,900 to 2,900/µL. Which is the appropriate nursing intervention?
- A. Continue monitoring the client.
- B. Call the laboratory to verify the report.
- C. Document the finding.
- D. Call the physician and place the client in reverse isolation.
Correct Answer: D
Rationale: A significant drop in WBC count (3,900 to 2,900/µL) in aplastic anemia indicates worsening neutropenia, increasing infection risk. The nurse should notify the physician and place the client in reverse isolation to protect against infections. Monitoring, verifying, or documenting alone are insufficient given the urgency.
The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:
- A. Assess breath sounds.
- B. Remove the catheter.
- C. Insert a peripheral I.V.
- D. Reposition the client.
Correct Answer: A
Rationale: Restlessness and tachypnea post-catheter insertion suggest a pneumothorax, a complication. Assessing breath sounds detects absent or diminished sounds, guiding intervention. Removing the catheter, inserting an I.V., or repositioning does not address the urgent issue.
The expected outcome of using miotics to treat glaucoma is:
- A. Paralyzing ciliary muscles.
- B. Constricting intraocular vessels.
- C. Constricting the pupil.
- D. Relaxing ciliary muscles.
Correct Answer: C
Rationale: Miotics (e.g., pilocarpine) constrict the pupil, which opens the drainage angle of the eye, facilitating aqueous humor outflow and reducing intraocular pressure.