Nokea
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is such that she is in a trancelike state.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.
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The client with varicella will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Varicella (chickenpox) is a viral infection, and antivirals like acyclovir are commonly prescribed to reduce severity and duration.
Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:
- A. Methergine
- B. Stadol
- C. Magnesium sulfate
- D. Phenergan
Correct Answer: A
Rationale: Methergine promotes uterine contractions to control postpartum hemorrhage, indicated for heavy lochia with clots.
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV. Which site would be most suitable for this client?
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable as it is away from burned areas (hands, right arm, face, neck) and provides a large vein for IV access.
The nurse is caring for a client who has just returned from surgery for an ascending colostomy. The nurse plans to include reinforcement teaching for the client and spouse. Which statements should the nurse include in the teaching? Select all that apply.
- A. The colostomy will begin functioning within 24 hours.
- B. A large amount of bleeding may be present at the stoma site.
- C. The first stools will be liquid and will gradually become more formed.
- D. A healthy stoma is reddish-pink and moist and protrudes about 2 cm from the abdominal wall.
Correct Answer: C,D
Rationale: A healthy stoma is reddish-pink, moist, and protrudes slightly (D). Initial stools are liquid, becoming formed over time (C). Function typically starts in 2-5 days, not 24 hours (A), and significant bleeding (B) is abnormal.
A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
- A. Gastric distress
- B. Changes in hearing
- C. Red discoloration of body fluids
- D. Changes in color vision
Correct Answer: D
Rationale: Ethambutol can cause optic neuritis, leading to changes in color vision, a serious side effect requiring immediate medical attention.