Nokea
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.
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A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply.
- A. Cardiac pacemaker
- B. Colostomy
- C. Retained metal foreign body in eye
- D. Total hip replacement
- E. Transdermal testosterone patch
Correct Answer: A,C,D
Rationale: Pacemakers, metal in the eye, and hip replacements pose MRI risks due to magnetic interference or heating. Colostomies and transdermal patches are not contraindicated for MRI.
The nurse is caring for a client who had a seizure 10 minutes ago. The client is now confused and reports a headache. Which of the following phases of seizure activity should the nurse recognize the client is experiencing?
- A. Ictal phase
- B. Aural phase
- C. Postictal phase
- D. Prodromal phase
Correct Answer: C
Rationale: The postictal phase follows a seizure, characterized by confusion and headache as the brain recovers. Ictal is the seizure itself, aural involves pre-seizure sensations, and prodromal is vague premonitory symptoms.
The nurse is reinforcing health promotion education to the parents of a toddler. Which statement by a parent requires the nurse to clarify teaching?
- A. I will offer my child options rather than asking yes or no questions
- B. I will wait at least 15 minutes after a play period to offer a meal to my child
- C. If my child is having a tantrum, I will have them sit in a quiet area for a short time-out
- D. If my child refuses a meal, I will have them stay at the table until they eat half the food.
Correct Answer: B
Rationale: Waiting 15 minutes after play to offer a meal is unnecessary and may disrupt healthy eating habits. Offering options and using time-outs are age-appropriate parenting strategies.
The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?
- A. Urinary output of $60 \mathrm{ml}$ per hour
- B. Respirations of 30 per minute
- C. Absence of the knee-jerk reflex
- D. Blood pressure of $150 / 80$
Correct Answer: C
Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.
A client is admitted to the burn unit with an electrical burn. Which of the following areas probably sustained the greatest degree of injury?
- A. The skin
- B. The intrathoraxic
- C. The muscles supporting the long bones
- D. The bones
Correct Answer: B
Rationale: Electrical burns cause deep tissue damage, with intrathoracic organs (heart, lungs) at greatest risk due to the current's path through the body.