Nokea
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Neosporin sulfate
- B. Mafenide acetate
- C. Silver sulfadiazine
- D. Povidone-iodine
Correct Answer: B
Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.
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The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. Apple
- D. Milkshake
Correct Answer: C
Rationale: An apple is a healthy, easy-to-eat snack that provides nutrition without excessive sodium (chips), caffeine (cola), or high calories (milkshake), suitable for a manic client needing stability.
A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?
- A. Partial thromboplastin time
- B. Hemoglobin
- C. Red blood cell (RBC) count
- D. Prothrombin time
Correct Answer: A
Rationale: Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. Hemoglobin is the main component of RBCs. Its main function is to carry O2 from the lungs to the body tissues and to transport CO2 back to the lungs. RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. PT is used to monitor the effects of oral anticoagulants, e.g., coumarin-type anticoagulants.
The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?
- A. Ultrasound
- B. Fetal heart monitoring
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.
A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:
- A. It is determined that he has no signs of wound infection
- B. He is able to eat a full meal without evidence of nausea or vomiting
- C. The nurse can detect bowel sounds in all four quadrants
- D. His blood pressure returns to its preoperative baseline level or greater
Correct Answer: C
Rationale: The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.
Which situation would be reportable to the state board of nursing?
- A. The facility fails to provide literature in both Spanish and English.
- B. The narcotic count has been incorrect on the unit for the past three days.
- C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
- D. Needles and sharps are found in the client's waste can.
Correct Answer: B
Rationale: An incorrect narcotic count for three days suggests potential diversion or mismanagement of controlled substances a serious issue reportable to the state board of nursing. The other situations are administrative or safety issues but not typically reportable to the board.