Nokea
The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
- A. Pupillary changes
- B. Projectile vomiting
- C. Wheezing respirations
- D. Sudden, intense pain
Correct Answer: A
Rationale: After administering naloxone, the nurse should assess for pupillary changes, as reversal of opioid effects can cause sympathetic stimulation, affecting pupil size.
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During the nurse's assessment of a client who has been diagnosed with anorexia nervosa, the nurse evaluates certain characteristics that accompany an intense fear of gaining weight. What characteristics are most applicable? Select all that apply.
- A. fatigue
- B. excessive exercise regime
- C. normal weight
- D. high blood pressure
Correct Answer: A,B
Rationale: Fatigue and excessive exercise are common in anorexia nervosa due to malnutrition and compulsive behaviors. Normal weight or high blood pressure are less typical.
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
- A. A 6-month-old
- B. A 4-year-old
- C. A 12-year-old
- D. A 13-year-old
Correct Answer: B
Rationale: A 4-year-old is at greatest risk due to their curiosity, mobility, and tendency to explore their environment, often putting objects in their mouths.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
The mother of a 24-month-old child tells the nurse that she is concerned that her child's language abilities are delayed. Which of the following language milestones does the nurse expect the child to exhibit?
- A. Understands 300 words and uses two- and three-word sentences.
- B. Says and understands a few words, such as 'Mama' and 'Dada,' and can imitate animal sounds, such as 'moo' and 'woof.'
- C. Says and understands four to six words but understands more and can point to items he wants.
- D. Says and understands up to 20 words and can point to his body parts.
Correct Answer: A
Rationale: A 24-month-old should understand about 300 words and use two- to three-word sentences (A). Other options (B, C, D) describe earlier developmental stages.
A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client's diagnosis?
- A. Smoking a pack of cigarettes a day for 30 years
- B. Use of nonsteroidal anti-inflammatories
- C. Eating foods with preservatives
- D. Past employment involving asbestos
Correct Answer: A
Rationale: Long-term smoking is a major risk factor for bladder cancer due to carcinogenic chemicals in tobacco being excreted in urine, irritating the bladder.