Nokea
The primary nurse is administering medications to the assigned clients. Which client situation requires immediate intervention by the charge nurse?
- A. The client with congestive heart failure with an apical pulse of 64 who received 0.125 mg digoxin, a cardiac glycoside.
- B. The client with essential hypertension who received a beta blocker and has a blood pressure of 114/80.
- C. The client with myasthenia gravis who received the anticholinesterase medication 30 minutes late.
- D. The client with AIDS who received trimethoprim-sulfamethoxazole, an antibiotic, and has a CD4 cell count of less than 200.
Correct Answer: C
Rationale: A 30-minute delay in anticholinesterase for myasthenia gravis risks muscle weakness exacerbation, requiring intervention. Digoxin, beta blocker, and antibiotic administration are appropriate.
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The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?
- A. The client has no apparent change in the assessment data.
- B. There is increased amplitude of electrical stimulation in the muscle.
- C. The circulating acetylcholine receptor antibodies are decreased.
- D. The client shows a marked improvement of muscle strength.
Correct Answer: D
Rationale: The Tensilon test improves muscle strength in myasthenia gravis by inhibiting acetylcholinesterase. No change, electrical stimulation, or antibody levels are not diagnostic.
The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves?
- A. Use only sterile, nonlatex gloves for any procedure requiring gloves.
- B. Do not use gloves when starting an IV or performing a procedure.
- C. Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform.
- D. Wear white cotton gloves at all times to protect the hands.
Correct Answer: C
Rationale: Carrying nonsterile, nonlatex gloves ensures safe practice for a latex-allergic nurse. Sterile gloves are unnecessary, avoiding gloves risks infection, and cotton gloves are inadequate.
The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules?
- A. The nodules indicate a rapidly progressive destruction of the affected tissue.
- B. The nodules are small amounts of synovial fluid that have become crystallized.
- C. The nodules are lymph nodes which have proliferated to try to fight the disease.
- D. The nodules present a favorable prognosis and mean the client is better.
Correct Answer: B
Rationale: RA nodules are granulomas, sometimes containing synovial fluid, due to chronic inflammation. They do not indicate rapid destruction, lymph node proliferation, or better prognosis.
The client diagnosed with an anaphylactic reaction is admitted to the emergency department. Which assessment data indicate the client is not responding to the treatment?
- A. The client has a urinary output of 120 mL in two (2) hours.
- B. The client has an AP of 110 and a BP of 90/60.
- C. The client has clear breath sounds and an RR of 26.
- D. The client has hyperactive bowel sounds.
Correct Answer: B
Rationale: Hypotension (BP 90/60) and tachycardia (AP 110) indicate ongoing anaphylaxis despite treatment. Normal urine output, clear lungs, and bowel sounds suggest improvement.
Which statement by the client supports the diagnosis of Guillain-Barré syndrome?
- A. I just returned from a short trip to Japan.
- B. I had a really bad cold just a few weeks ago.
- C. I think one of the people I work with had this.
- D. I have been taking some herbs for more than a year.
Correct Answer: B
Rationale: A recent viral infection (e.g., cold) is a common trigger for Guillain-Barré syndrome. Travel, coworker illness, and herbs are less relevant.