Nokea
The physician has inserted an esophageal balloon tamponade in a client with bleeding esophageal varices. The nurse should maintain the esophageal balloon at a pressure of:
- A. 5-10 mmHg
- B. 10-15 mmHg
- C. 15-20 mmHg
- D. 20-25 mmHg
Correct Answer: D
Rationale: A pressure of 20-25 mmHg effectively compresses varices to control bleeding without causing tissue damage.
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The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
- A. Application of a short inclusive spica cast
- B. Stabilization with a plaster-of-Paris cast
- C. Surgery with Kirschner wire implantation
- D. A gauze dressing only
Correct Answer: B
Rationale: A plaster-of-Paris cast is typically used to stabilize foot fractures, ensuring proper alignment and healing.
A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, urine output of 20 cc in 2 hours, and crackles on auscultation. Which order would the nurse anticipate from the physician?
- A. Furosemide (Lasix) IV push
- B. Irrigate the Foley catheter
- C. Increase the IV fluids to 200 mL/hr
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Signs of fluid overload (JVD, edema, low urine output, crackles) suggest the need for furosemide (Lasix) to reduce excess fluid and prevent pulmonary edema.
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- A. Taking hourly blood pressures with mechanical cuff
- B. Encouraging fluid intake of at least 200 mL per hour
- C. Position in high Fowler's with knee gatch raised
- D. Administering Tylenol as ordered
Correct Answer: B
Rationale: Hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and to promote blood flow, reducing the risk of complications.
The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the client's mouth using:
- A. A toothbrush
- B. A soft gauze pad
- C. Antiseptic mouthwash
- D. Lemon and glycerin swabs
Correct Answer: B
Rationale: A soft gauze pad is gentle and effective for cleaning the mouth in oral candidiasis without causing trauma.
The physician has prescribed Chloromycetin (chloramphenicol) for a client with bacterial meningitis. Which lab report should the nurse monitor most carefully?
- A. Serum creatinine
- B. Urine specific gravity
- C. Complete blood count
- D. Serum sodium
Correct Answer: C
Rationale: Chloramphenicol can cause bone marrow suppression, so monitoring the complete blood count is critical.