Nokea
The physician has prescribed Oxycontin (oxycodone) for a client following an exploratory laparotomy. Which of the following is an adverse effect associated with the medication?
- A. Pulmonary edema
- B. Increased blood pressure
- C. Nervousness
- D. Rapid pulse
Correct Answer: C
Rationale: Oxycontin, an opioid, can cause nervousness or restlessness as a central nervous system side effect, alongside more common effects like sedation or respiratory depression. Pulmonary edema, increased blood pressure, and rapid pulse are not typical.
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Chorioamnionitis is a maternal infection that is usually associated with:
- A. Prolonged rupture of membranes
- B. Postterm deliveries
- C. Maternal pyelonephritis
- D. Maternal dehydration
Correct Answer: A
Rationale: Chorioamnionitis is an inflammation of the chorion and amnion that is generally associated with premature or prolonged rupture of membranes.
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Hemolytic transfusion reaction
- B. Febrile transfusion reaction
- C. Circulatory overload
- D. Allergic transfusion reaction
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed?
- A. The physician verifies the exact time of birth.
- B. The nurse counts the instruments and sponges with the scrub nurse.
- C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes.
- D. The nurse makes sure the mother and her newborn have been tagged with identical bands.
Correct Answer: D
Rationale: Tagging the mother and infant with identical bands ensures proper identification, preventing mix-ups and ensuring safety.
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Hypovolemia
- B. Renal damage
- C. Ventricular arrhythmias
- D. Loss of peripheral pulses
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.
A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.