Nokea
When another nurse enters the room in response to a call, after checking the client's pulse and respirations during CPR on an adult in cardiopulmonary arrest, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: The correct answer is to participate in compressions or breathing. This is essential to ensure continuous and effective CPR. Relieving the nurse performing CPR (Choice A) is not recommended as it can interrupt the life-saving procedure. Going to get the code cart (Choice B) may be necessary in certain situations but should not take precedence over providing immediate assistance in CPR. Validating the client's advanced directive (Choice D) is not the primary role in this scenario where urgent action is needed to support the client's circulation and breathing.
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A nurse is reinforcing teaching about foods that enhance iron absorption when consumed with nonheme iron with a client who has iron deficiency anemia. Which of the following foods should the nurse include in the teaching?
- A. Tomato juice
- B. Tea
- C. Milk
- D. Dried beans
Correct Answer: A
Rationale: The correct answer is A, Tomato juice. Tomato juice is high in vitamin C, which enhances the absorption of nonheme iron from foods. Vitamin C helps convert nonheme iron to a form that is easier for the body to absorb. Tea (choice B) contains tannins that can inhibit iron absorption. Milk (choice C) contains calcium, which can interfere with iron absorption. Dried beans (choice D) are a good source of nonheme iron but do not enhance iron absorption when consumed with nonheme iron.
The nurse is caring for a client with a chest tube. Which of these assessments is a priority?
- A. Assessing for subcutaneous emphysema
- B. Assessing for signs of infection at the insertion site
- C. Monitoring the client's respiratory status
- D. Checking the chest tube for kinks or occlusions
Correct Answer: B
Rationale: Assessing for signs of infection at the insertion site is the priority when caring for a client with a chest tube. Infection at the insertion site can lead to serious complications such as empyema or sepsis. Monitoring respiratory status is essential but assessing for infection takes precedence to prevent immediate harm. Assessing for subcutaneous emphysema is important but not the priority unless it compromises respiratory function. Checking the chest tube for kinks or occlusions is crucial for proper drainage but is not the priority when infection is a concern.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. Abdominal x-ray
- B. Auscultation
- C. Flushing tube with saline
- D. Aspiration for gastric contents
Correct Answer: D
Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.
The nurse is caring for a client with liver cirrhosis. Which of these findings would indicate that the client is experiencing complications of the disease?
- A. Yellowing of the skin and eyes
- B. Presence of spider angiomas on the skin
- C. Ascites and peripheral edema
- D. Clay-colored stools and dark urine
Correct Answer: D
Rationale: Clay-colored stools and dark urine are classic signs of liver dysfunction, indicating bile flow obstruction commonly seen in liver cirrhosis. This finding is a significant complication requiring immediate medical evaluation. Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction but is not specific to complications. Spider angiomas and ascites with peripheral edema are also associated with liver cirrhosis, but they are not indicative of immediate complications as clay-colored stools and dark urine are.
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
- A. Bruising at the operative site
- B. Elevated heart rate
- C. Decreased platelet count
- D. No bowel movement for 3 days
Correct Answer: D
Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.