Nokea
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
- A. Increased appetite
- B. Elevated liver enzymes
- C. Hypotension
- D. Improved short-term memory
Correct Answer: B
Rationale: Elevated liver enzymes are a key adverse reaction to Cognex, requiring monitoring in dementia appetite, BP, and memory aren't primary concerns. Nurses check LFTs, ensuring safety, critical for managing Alzheimer's medication risks.
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The nurse is providing care for a client with a chest tube. If the chest tube becomes disconnected from the drainage system, the nurse should:
- A. Secure the chest tube with tape and notify the physician
- B. Clamp the chest tube near the insertion site
- C. Submerge the end of the tube in sterile water
- D. Insert the tube into the drainage system without cleansing
Correct Answer: C
Rationale: Submerging the chest tube end in sterile water creates a water seal, preventing pneumothorax if disconnected taping delays, clamping risks tension pneumothorax, and reinserting uncleaned spreads infection. Nurses act quickly, ensuring lung re-expansion, critical in chest tube care.
The nurse is preparing to administer regular insulin to a client with type 1 diabetes. Before administering the insulin, the nurse should:
- A. Rotate the vial between her hands
- B. Warm the insulin to body temperature
- C. Shake the vial vigorously
- D. Draw up the insulin with an 18-gauge needle
Correct Answer: A
Rationale: Rotating the vial between hands mixes regular insulin gently, ensuring even suspension without denaturing it warming, shaking, or large needles risk potency loss or tissue damage. Nurses use this technique, confirming clarity, for safe, effective glycemic control in type 1 diabetes.
Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is
- A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues
- B. It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
- C. It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent contamination
- D. It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet dressing to stimulate healing of the wound in a wet medium
Correct Answer: A
Rationale: The wet-to-dry dressing method (A) is a mechanical debridement technique where a wet gauze is applied to a wound, then dries, adhering to and removing necrotic tissue when peeled off. Surgical debridement (B) involves cutting, not dressings. Option C misrepresents it as a protective dressing, ignoring debridement. Option D describes wet-to-moist dressings, not wet-to-dry. Wet-to-dry targets dead tissue removal, aiding healing in wounds like Imelda's, making A accurate and the best response.
When caring for a client with a spinal cord injury, the nurse continually monitors this client for which medical emergency?
- A. Hemorrhage
- B. Hypovolemic shock
- C. Gastrointestinal atony
- D. Autonomic hyperreflexia
Correct Answer: D
Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.
During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?
- A. What is your marital status?
- B. How would you describe yourself?
- C. Are you employed?
- D. Do you have any children?
Correct Answer: B
Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.