Nokea
The physician has ordered Amoxil (amoxicillin) 500 mg capsules for a client with esophageal varices. The nurse can best care for the client's needs by:
- A. Giving the medication as ordered
- B. Providing extra water with the medication
- C. Giving the medication with an antacid
- D. Requesting an alternate form of the medication
Correct Answer: D
Rationale: Capsules can be difficult to swallow and may lodge in esophageal varices, increasing the risk of bleeding. An alternate form, such as a liquid, is safer.
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A client in ICU has a chest tube, and the nurse is assessing the chest tube drainage system. The nurse notices intermittent bubbling in the water seal chamber. What action should the nurse take?
- A. clamp the chest tube and call for help
- B. document the findings in the client chart
- C. document an air leak and notify the physician
- D. call the physician to report the findings
Correct Answer: B
Rationale: Intermittent bubbling in the water seal chamber is normal during inspiration/expiration or coughing, indicating a patent system. It should be documented as a normal finding.
A client is admitted to the surgical unit following a transurethral prostatectomy (TURP). The nurse administers a B&O suppository to help prevent bladder spasms. The nurse would observe the client for:
- A. Insomnia and hyperactivity
- B. Physiological dependence on the drug
- C. Nausea and vomiting
- D. Diarrhea and abdominal cramping
Correct Answer: C
Rationale: Belladonna and opium (B&O) suppositories can cause nausea and vomiting as side effects. These are more immediate concerns than dependence or the other symptoms.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- A. Russell's traction
- B. Buck's traction
- C. Halo traction
- D. Crutchfield tong traction
Correct Answer: C
Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.
An 82-year-old woman is being admitted to a long-term care facility. Her assigned nurse completes a full assessment, including calculating the risk for skin breakdown based on the Braden Scale. To determine a Braden Scale score, the nurse evaluates all of the following EXCEPT
- A. nutritional status.
- B. sensory perception.
- C. past history of skin breakdown.
- D. activity level.
Correct Answer: C
Rationale: The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Past history of skin breakdown is not a scored category.
A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
- A. Prevent swelling and dysphagia
- B. Decompress the stomach
- C. Prevent contamination of the suture line
- D. Promote healing of the oral mucosa
Correct Answer: B
Rationale: A nasogastric tube decompresses the stomach, preventing nausea and aspiration post-laryngectomy.