Nokea
The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.'
- A. What is the best action for the nurse to take for a client one-day post-angioplasty who refuses to eat and feels unwell?
- B. The nurse talks with the client about how he is feeling.
- C. The nurse instructs the nursing assistant to sit with the client while he eats.
- D. The nurse contacts the physician to obtain an order for an antacid.
- E. The nurse evaluates the most recent vital signs recorded in the chart.
Correct Answer: A
Rationale: Assessment is required to determine the cause of the client’s symptoms, as they could indicate complications such as vessel closure, bleeding, hypotension, or dysrhythmias. Talking with the client to assess current symptoms is the most immediate and appropriate action. Encouraging eating, ordering medication, or reviewing past vital signs does not address the need for current assessment.
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A client administering his own insulin.
Which observation indicates to the nurse that the client needs further teaching before he can administer his own insulin?
- A. The client draws up his regular insulin first, then the NPH.
- B. The client gently rotates the insulin bottle before withdrawing the dose.
- C. The client rotates injection sites following the guide on his printed diagram.
- D. The client administers the insulin while it is still cold from the refrigerator.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH) (2) bottle of insulin should never be vigorously shaken, but rather gently mixed (3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption (4) correct-insulin should be administered at room temperature, temperature extremes should be avoided
The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a 47-year-old woman. The nurse in the outpatient clinic teaches the client about the medication. The nurse should encourage the client to make sure her diet has adequate
- A. sodium.
- B. protein.
- C. potassium.
- D. iron.
Correct Answer: A
Rationale: alkali metal salt acts like sodium ions in body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity
A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of the following situations?
- A. The student nurse selects a site where the veins are soft and elastic.
- B. The student nurse selects a site on the distal portion of the left arm.
- C. The student nurse selects a site close to the joint to provide for stability.
- D. The student nurse holds the skin taut to stabilize the vein.
Correct Answer: C
Rationale: inappropriate; movement in area could cause displacement
An adult who has multiple sclerosis is receiving cyclophosphamide (Cytoxan). The client asks the nurse why she is receiving the same drug her mother had when she had Hodgkin's disease. The nurse should include which information when responding?
- A. Multiple sclerosis is a type of cancer, so the same drugs are effective for both conditions.
- B. A side effect of cyclophosphamide (Cytoxan), a cancer drug, is immunosuppression. In multiple sclerosis, the immune system is attacking the client's nerves.
- C. Hodgkin's disease causes nervous system symptoms similar to those seen in multiple sclerosis.
- D. Multiple sclerosis and Hodgkin's disease are caused by the same organism, so the same drug is appropriate.
Correct Answer: B
Rationale: Cyclophosphamide's immunosuppressive effect reduces immune activity in MS, where the immune system attacks nerves, unlike cancer treatment, symptom similarity, or shared etiology.
A patient has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the woman in respiratory distress.
It is MOST important for the nurse to
- A. notify the physician immediately to remove the tube.
- B. elevate the head of the bed and administer oxygen.
- C. cut the balloon ports and remove the tube.
- D. call a code and begin rescue breathing.
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) need to remove tube immediately to provide for airway (2) does not provide a patent airway (3) correct-scissors always secured at the bedside, remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon (4) unnecessary to call code until respiratory arrest occurs, then establish a patent airway first