Nokea
The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: D
Rationale: The correct answer is D: Hematoma over the insertion site. This finding indicates potential internal bleeding, which can lead to complications. Notify the provider to assess and manage promptly. A: Discomfort at insertion site is common post-procedure and can be managed with appropriate interventions. B: Heart rate of 90/min is within normal range and does not require immediate provider notification. C: Bounding pulses in the affected extremity may indicate adequate perfusion and is not a concerning finding.
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Which of the following actions should the nurse take?
- A. Administer dextrose 10% in water.
- B. Give 500 mL of lactated Ringers solution.
- C. Slow the TPN infusion rate.
- D. Temporarily discontinue the infusion
Correct Answer: A
Rationale: The correct answer is A: Administer dextrose 10% in water. This action is appropriate for treating hypoglycemia, which can be a potential complication of TPN (Total Parenteral Nutrition) therapy. Administering dextrose 10% in water can help raise the patient's blood sugar levels quickly and effectively. Choice B is incorrect as lactated Ringers solution does not directly address hypoglycemia. Choice C is not the best option as slowing the TPN infusion rate may further decrease the patient's blood sugar levels. Choice D is also incorrect as temporarily discontinuing the TPN infusion may exacerbate the hypoglycemia.
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Apply suction while rotating the catheter.
- B. Rinse the catheter to remove secretions:
- C. Dan sterile gloves.
- D. Insert the catheter during the client's inspiration.
- E. Turn on the suction and set the pressure
Correct Answer: C,D,E,A,B
Rationale: To perform nasotracheal suctioning correctly, the nurse should follow these steps:
1. Dan sterile gloves (C): Ensures aseptic technique to prevent infection.
2. Insert the catheter during the client's inspiration (D): Reduces the risk of hypoxia and trauma.
3. Turn on the suction and set the pressure (E): Prepares the equipment for suctioning.
4. Apply suction while rotating the catheter (A): Maximizes removal of secretions.
5. Rinse the catheter to remove secretions (B): Ensures cleanliness of the catheter for next use.
Other choices are incorrect:
- F and G are not applicable in this sequence as they do not contribute to the safe and effective performance of nasotracheal suctioning.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Instruct the client to avoid live vaccines, Instruct the client to use mild soaps for cleansing skin, Instruct the client to avoid foods high in purities, Instruct the client to apply tropical analgesics, Instruct the client to apply heat
- B. Systemic lupus erythematous, Osteoarithritis, Gout, Rheumatoid arthritis(RA)
- C. Uric acid level, ESH, Joint deformities, lymphadenopathy, ANA
Correct Answer:
Rationale: Gout presents with elevated uric acid levels.
A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
- A. Administer oral acetaminophen.
- B. Cover the adolescent with a thermal blanket
- C. Submerge the adolescent's feet in ice water
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. Hyperthermia can lead to seizures due to the brain's sensitivity to high temperatures. Seizure precautions involve ensuring a safe environment, padding the bed, and having emergency equipment ready. Administering oral acetaminophen (A) is not the priority in hyperthermia as it may not rapidly reduce the temperature. Covering with a thermal blanket (B) may further increase body temperature. Submerging feet in ice water (C) can cause vasoconstriction and shivering, leading to increased core temperature.
Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg rectal suppository. Bisacodyl is indicated for immediate relief of constipation as a rectal suppository. It acts directly on the colon to stimulate peristalsis and promote bowel movement. The rectal route ensures faster onset of action compared to oral medications, making it suitable for a patient needing immediate relief. Magnesium hydroxide (B) is a laxative taken orally, which may not provide quick relief. Famotidine (C) is for acid reflux, not constipation. Loperamide (D) is an antidiarrheal agent, not appropriate for constipation.