Nokea
The nurse plans care for a 36-year-old woman with Graves' disease. The nurse knows that which of the following foods or fluids should be restricted for this client?
- A. Milk.
- B. Apples.
- C. Orange juice.
- D. Tea.
Correct Answer: D
Rationale: Tea contains caffeine, which can exacerbate hyperthyroidism symptoms like tachycardia in Graves’ disease. Options A, B, and C are not contraindicated.
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The nurse prepares a 25-year-old woman for a cesarean section.
- A. What should the nurse’s response be based on regarding preoperative medication for a cesarean section?
- B. Contains a lower overall dosage of medication than is given before general surgery.
- C. Contains reduced amounts of sedatives and hypnotics than are given before general surgery.
- D. Contains reduced amounts of narcotics than are given before general surgery.
- E. Contains medications similar in type and dosages to those given before general surgery.
Correct Answer: C
Rationale: Preoperative medication for a cesarean section includes reduced amounts of narcotics to minimize respiratory depression in the newborn due to placental transfer. Sedatives and hypnotics are typically used in similar doses as in general surgery, and the overall dosage is not necessarily lower.
In addition to standard precautions, a nurse should implement contact precautions for which client?
- A. 60 year-old with herpes simplex
- B. 6 year-old with mononucleosis
- C. 45 year-old with pneumonia
- D. 3 year-old with scarlet fever
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 90 bpm.
- C. Facial flushing and itching.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
An infant is suspected of having coarctation of the aorta. Which assessment finding is most related to coarctation of the aorta?
- A. Respirations are 70 per minute.
- B. Blood pressure is higher in the upper extremities than in the lower extremities.
- C. There is a heart murmur.
- D. Heart rate is 150 beats per minute.
Correct Answer: B
Rationale: Coarctation of the aorta causes aortic narrowing, leading to higher blood pressure in the upper extremities compared to the lower, a hallmark sign.
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.