Nokea
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms?
- A. Sore throat and muscle aches.
- B. Nausea and flushing of the face and neck.
- C. Fever and muscle soreness.
- D. Bradycardia and vertigo.
Correct Answer: B
Rationale: Disulfiram causes an adverse reaction with alcohol, leading to symptoms like nausea and flushing due to acetaldehyde accumulation.
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The nurse is caring for a client who has just undergone a coronary artery bypass graft (CABG). Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bleeding.
- B. Encourage deep breathing exercises.
- C. Administer oral pain medications.
- D. Restrict all visitors.
Correct Answer: A
Rationale: Monitoring for bleeding is critical post-CABG due to the risk of hemorrhage from the surgical site or anticoagulation therapy.
The client with a nasogastric (NG) tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first?
- A. Call the physician.
- B. Irrigate the NG tube.
- C. Check the function of the suction equipment.
- D. Reposition the NG tube.
Correct Answer: C
Rationale: Checking the suction equipment ensures the NG tube is functioning properly, addressing the most likely cause of distention before escalating to other interventions.
The nurse has assisted the primary health care provider in placing a central (subclavian) catheter. Which priority action should the nurse take after the procedure?
- A. Ensure that a chest radiograph is done.
- B. Obtain a temperature reading to monitor for infection.
- C. Label the dressing with the date and time of catheter insertion.
- D. Monitor the blood pressure (BP) to check for fluid volume overload.
Correct Answer: A
Rationale: A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and verify catheter tip placement before initiating intravenous (IV) therapy. Although a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. Labeling the dressing site is important, but it is not a priority action in this situation. Although BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.
You have collected, aggregated and analyzed data which reflects the frequency of your staff returning medical equipment to the appropriate department because the staff members thought it was too unsafe to use. After the experts in the medical equipment inspect and test the equipment they report back to you, as the nurse manager, whether or not the equipment was indeed unsafe. This data indicates that 83% of the returns that were made by your staff were deemed safe and operable. What should you do?
- A. Counsel the staff about their need to stop wasting the resources of this department.
- B. Check the equipment yourself to determine the accuracy of this equipment department.
- C. Ignore it because everyone can make an innocent mistake.
- D. Plan an educational activity about determining what equipment to send for repairs.
Correct Answer: D
Rationale: The high rate of unnecessary returns (83% safe equipment) indicates a knowledge deficit among staff about assessing equipment safety. Planning an educational activity addresses this issue effectively.
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
- A. Resume normal diet immediately
- B. Report fever or yellowing of skin
- C. Avoid bathing for 2 weeks
- D. Lift heavy objects as tolerated
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.