Nokea
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
- A. I can lay my child flat and feed that way.'
- B. I'll raise my child's head up and leave the hips and legs on a pillow.'
- C. I can borrow a special feeding table to use.'
- D. It will take two of us, one to hold and one to feed.'
Correct Answer: B
Rationale: Raising the infant's head while keeping the hips and legs supported minimizes the risk of aspiration and accommodates the hip spica cast's restrictions. Laying flat increases aspiration risk, and the other options are impractical or unnecessary.
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An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
- A. Excitability
- B. Bradycardia
- C. Hypertension
- D. Poor skin turgor
- E. Flat peripheral veins
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
- A. Remove any dentures.
- B. Remove contact lenses.
- C. Provide access to limited food and drink.
- D. Ensure that the informed consent is signed.
- E. Have the client void before transport to endoscopy.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.
A client has been prescribed metoclopramide on a long-term basis. A home care nurse calls the primary health care provider immediately if which side effect is noted in this client?
- A. Excitability
- B. Anxiety or irritability
- C. Uncontrolled rhythmic movements of the face or limbs
- D. Dry mouth not minimized by the use of sugar-free hard candy
Correct Answer: C
Rationale: Metoclopramide is a 'prokinetic' drug used to treat heartburn. If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should withhold the medication and call the primary health care provider. These side effects may be irreversible. Excitability is not a side effect of this medication. Anxiety, irritability, and dry mouth are milder side effects that are not harmful to the client.
Which tool or scale would you use for a focused neurological assessment of your client?
- A. The Lazarus Cognitive Appraisal Scale
- B. The Hamilton Rating Scale
- C. The McGill Scale
- D. The Rancho Los Amigos Scale
Correct Answer: D
Rationale: The Rancho Los Amigos Scale is used for assessing levels of consciousness and cognitive recovery in patients with brain injuries, ideal for a focused neurological assessment.
A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?
- A. Document these results on the medical record.
- B. Report the elevated potassium level immediately.
- C. Report the elevated calcium level immediately.
- D. Refrain from reporting the results because the client is in hospice care.
Correct Answer: C
Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.