Nokea
The nurse performs a routine IV tubing change on a 55-year-old woman with a central line. Fifteen minutes later, the nurse reenters the patient's room to find her cyanotic, short of breath, and complaining of pain. Her vital signs are BP 84/62, pulse 112, respirations 18.
What is the FIRST action the nurse should take?
- A. Call the physician to report the patient's symptoms.
- B. Lower the head of the bed and place the patient on her left side.
- C. Place the patient in high Fowler's position.
- D. Start oxygen at 4 L/min via nasal cannula.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) second action, first should respond to potential problem of emboli (2) correct-air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation (3) never done with shock, trapped air could travel to pulmonary circulation (4) not first action
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A teenager comes to the clinic complaining of fatigue, a sore throat, and flu-like symptoms for the previous two weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3°F (37.9°C). Which of the following statements by the nurse is BEST?
- A. Cover your mouth and nose when you sneeze or cough.
- B. Eat in a separate room away from your family.
- C. Don't share your drinking glass or silverware with anybody.
- D. Stay in your room until all of your symptoms are gone.
Correct Answer: C
Rationale: symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation
A client is admitted for treatment of severe anxiety. It is MOST important for the nurse to obtain which of following information during the first 48 hours after admission?
- A. What is important to the client.
- B. How the client views herself.
- C. In what situations the client gets anxious.
- D. If anyone in the client's family has had mental problems.
Correct Answer: C
Rationale: will provide necessary information in baseline assessment of client's anxiety
The nurse is caring for a client recently diagnosed with AIDS. Which of the following interventions by the nurse would be BEST?
- A. Inspect the skin daily for signs of breakdown.
- B. Limit the number of health care personnel caring for the patient.
- C. Utilize standard precautions when administering parenteral medications.
- D. Monitor the patient's vital signs q4h.
Correct Answer: B
Rationale: implementation, decreases exposure to microorganisms
The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he felt something give. The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient
- A. with the head of the bed elevated 30°.
- B. with the foot of the bed tilted and the head of the bed down.
- C. with the head of the bed elevated 15°.
- D. with the head of the bed elevated 90°.
Correct Answer: C
Rationale: low Fowler's, reduces stress on suture line, may be placed supine with hips and knees bent