Nokea
The sense of hearing is assessed using which standardized test?
- A. Taylor test
- B. Rinne test
- C. Babinski test
- D. APGAR test
Correct Answer: B
Rationale: The Rinne test assesses hearing by comparing air and bone conduction using a tuning fork. The Taylor test is not a standard hearing test, the Babinski test evaluates neurological reflexes, and the APGAR test assesses newborn health.
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The nurse is preparing to administer a unit of packed red blood cells (PRBCs). The nurse should
- A. obtain a bag of 250 mL of 0.9% saline.
- B. obtain a bag of 250 mL of Dextrose 5% in water (D5W).
- C. insert a 22 gauge intravenous (IV) catheter.
- D. initiate continuous telemetry monitoring.
Correct Answer: A
Rationale: 0.9% saline is required to prime the tubing for PRBC transfusions, as it is compatible and prevents hemolysis. D5W causes hemolysis, a 22-gauge catheter is too small for blood products, and telemetry is not routinely required.
A client with a history of heart failure has bilateral +4 edema of her right ankle that extends up to midcalf. She is sitting out of bed and has her legs in a dependent position. Which of the following goals is the priority?
- A. Decrease venous congestion
- B. Maintain normal respirations
- C. Maintain body temperature
- D. Prevent injury to lower extremities
Correct Answer: A
Rationale: Bilateral edema in heart failure results from increased venous pressure and congestion due to impaired cardiac output. The priority goal is to decrease venous congestion (e.g., by elevating legs or using compression) to reduce edema and improve circulation. Respirations, temperature, and injury prevention are secondary in this context.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
- A. Count the rate to be sure that ventilations are deep enough to be sufficient.
- B. Notify the physician of the client's breathing pattern.
- C. Increase the rate of ventilations.
- D. Increase the tidal volume on the ventilator.
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
The client with glaucoma is scheduled for a hip replacement. Which of the following orders would require clarification before the nurse carries it out?
- A. Administer morphine sulfate.
- B. Administer atropine sulfate.
- C. Teach deep-breathing exercises.
- D. Teach leg lifts and muscle-setting exercises.
Correct Answer: B
Rationale: Atropine sulfate can increase intraocular pressure, which is contraindicated in glaucoma. The nurse should clarify this order to ensure it is safe for the client.
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
- A. Checking the hemoglobin levels before administering subsequent doses.
- B. Shaking the vial thoroughly to mix the concentrated white, milky solution.
- C. Keeping the multidose vial refrigerated between scheduled twice-a-day doses.
- D. Administering the medication through the I.V. line without other medications.
- E. Adjusting the initial doses according to the client's changes in blood pressure.
- F. Educating the client to avoid driving and performing hazardous activity during the initial treatment.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.