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The nursing team consists of an RN who has been practicing for 6 months, a LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients?
- A. A client 1-day postoperative after an internal fixation of a fractured left femur.
- B. A client receiving diltiazem (Cardizem) and phenytoin (Dilantin).
- C. A client who is to receive 2 units of packed cells prior to an upper endoscopy procedure.
- D. A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.
Correct Answer: C
Rationale: Blood transfusions require RN assessment and teaching due to risks like transfusion reactions. Options A, B, and D can be assigned to the nursing assistant (postop care) or LPN (medication administration, bipolar care), as they involve standard procedures.
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The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first?
- A. Clear the area of any hazards
- B. Place the child on its side
- C. Restrain the child
- D. Give the prescribed anticonvulsant
Correct Answer: B
Rationale: Place the child on its side. Protecting the airway is the top priority in a seizure to ensure a patent airway and oxygenation.
The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is
- A. Drink 3000 to 4000 cc of fluid each day for one month.'
- B. Limit fluid intake to 1000 cc each day for one month.'
- C. Increase fluid intake for the next three days.'
- D. Restrict milk and dairy products for one month.'
Correct Answer: A
Rationale: Drink 3000 to 4000 cc of fluid each day for one month.' Drinking three to four quarts (3000 to 4000 cc) of fluid each day will aid passage of fragments and help prevent formation of new calculi.
The nurse is caring for a client with a history of stroke.
- A. Which intervention is most effective for preventing aspiration in a client with a history of stroke?
- B. Thicken liquids to a nectar consistency.
- C. Encourage small, frequent meals.
- D. Place the client in a supine position for meals.
- E. Administer an antiemetic before meals.
Correct Answer: A
Rationale: Thickening liquids to a nectar consistency slows swallowing, reducing aspiration risk in stroke patients with dysphagia. Small meals help, supine positioning increases risk, and antiemetics are irrelevant.
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on honey thick diet.
- B. Pain with a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: Bowel movement pain should be examined with a colonoscopy not an endoscopy.