Nokea
The sarge department (ED) nurse cares for a client with suspected shock and is prescribed a large volume of sodium chloride (normal saline) The nurse plans on starting which gauge peripheral vascular
- A. 18-gauge
- B. 22-gauge
- C. 24-gauge
- D. 26-gauge
Correct Answer: A
Rationale: An 18-gauge catheter is appropriate for rapid infusion of large fluid volumes in shock.
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The nurse is providing follow-up care to a client with tuberculosis who does not regularly take his medication. Which nursing action would be most appropriate for this client?
- A. Ask the client's spouse to supervise the daily administration of the medications.
- B. Visit the client weekly to ask him whether he is taking his medications regularly.
- C. Notify the physician of the client's noncompliance and request a different prescription.
- D. Remind the client that tuberculosis can be fatal if it is not treated promptly.
Correct Answer: A
Rationale: Having a spouse supervise medication administration ensures adherence, critical for tuberculosis treatment. Weekly visits are insufficient. Changing prescriptions doesn't address noncompliance. Fear-based reminders are less effective than direct support.
The nurse is caring for a client who ingested a lethal dose of aspirin (ASA). Which assessment finding is most concerning?
- A. Pulmonary edema
- B. Tinnitus
- C. Nausea and vomiting
- D. Tachycardia
Correct Answer: A
Rationale: Pulmonary edema is life-threatening and indicates severe aspirin toxicity, potentially leading to respiratory failure.
A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.
The nurse is teaching a group of teenage boys who are on a baseball team about the risks of chewing tobacco. Which of the following should the nurse instruct the teenagers to report to their parents and physicians? Select all that apply.
- A. Dysphagia.
- B. Sessibility in the
- C. Unexplained mouth pain.
- D. Lump in the neck.
- E. Decreased saliva.
- F. White patch on the mucosa.
Correct Answer: C,D,F
Rationale: Chewing tobacco is a known risk factor for oral cancer and other oral health issues. Symptoms such as unexplained mouth pain, a lump in the neck, and white patches on the mucosa are concerning and could indicate serious conditions like oral cancer or precancerous lesions, requiring immediate medical attention. Dysphagia and decreased saliva are less specific and not directly linked to chewing tobacco risks in this context.
Which of the following should be included in the teaching plan for a cancer client who is experiencing thrombocytopenia? Select all that apply.
- A. Use an electric razor.
- B. Use a soft-bristle toothbrush.
- C. Avoid frequent flossing for oral care.
- D. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control.
- E. Monitor temperature daily.
- F. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional.
Correct Answer: A,B,C,F
Rationale: Thrombocytopenia increases bleeding risk, so using an electric razor (A), soft-bristle toothbrush (B), avoiding flossing (C), and reporting bleeding (F) are critical to prevent and monitor bleeding complications. NSAIDs (D) are contraindicated, and temperature monitoring (E) is unrelated to thrombocytopenia.