Nokea
The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?
- A. A client 2 days post-appendectomy
- B. A client 1 week post-thyroidectomy
- C. A client 3 days post-splenectomy
- D. A client 2 days post-thoracotomy
Correct Answer: D
Rationale: A post-thoracotomy patient requires RN monitoring for respiratory complications.
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The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?
- A. Prepare the client for a caesarean section
- B. Apply the fetal heart monitor
- C. Place the client in the Trendelenburg position
- D. Perform an ultrasound exam
Correct Answer: B
Rationale: Applying the fetal heart monitor assesses fetal well-being in a breech presentation, guiding further management.
A client is to receive 1,000 mL of potassium chloride in 5% dextrose injection (D5W) intravenously over 3 hours and 20 minutes using a drop factor of 15 drops/mL. What is the required flow rate (drops) per minute? Record your answer using a whole number.
Correct Answer: 75
Rationale: To calculate the flow rate in drops per minute, use the formula: (Total volume X Drop factor)/ Total time in minutes. The total volume is 1,000 mL, the drop factor is 15 drops/mL, and the time is 3 hours 20 minutes = 200 minutes. Thus, (1,000 X 15)/ 200 = 15,000/ 200 = 75 drops/minute.
Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?
- A. Thiamine
- B. Niacin
- C. Pyridoxine
- D. Riboflavin
Correct Answer: C
Rationale: Pyridoxine (vitamin B6) is given with isoniazid to prevent peripheral neuropathy, a potential side effect of the medication.
Which developmental milestone puts the 4-month-old infant at greatest risk for injury?
- A. Switching objects from one hand to another
- B. Crawling
- C. Standing
- D. Rolling over
Correct Answer: D
Rationale: Rolling over at 4 months increases the risk of falling from elevated surfaces like changing tables, a common cause of injury.