Nokea
When monitoring a client who is receiving t-PA, the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
- A. Cardiac arrhythmias.
- B. Hypertension.
- C. Seizure.
- D. Hypothermia.
Correct Answer: A
Rationale: Reperfusion from t-PA can cause arrhythmias due to myocardial irritability as blood flow is restored, necessitating resuscitation equipment.
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Which outcome is appropriate for a client with a traumatic brain injury?
- A. Complete memory recovery.
- B. Active participation in therapy.
- C. Return to pre-injury job.
- D. Eliminate all symptoms.
Correct Answer: B
Rationale: Active participation in therapy is a realistic outcome for recovery in traumatic brain injury.
When caring for a client with a chest tube and water-seal drainage system, the nurse should:
- A. Verify that the air vent on the water-seal drainage system is capped when the suction is off.
- B. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs.
- C. Ensure that the chest tube is clamped when moving the client out of the bed.
- D. Make sure that the drainage apparatus is always below the client's chest level.
Correct Answer: D
Rationale: Keeping the drainage apparatus below chest level prevents fluid backflow into the pleural space. Capping the vent, stripping tubes, or clamping during movement risks complications like pneumothorax.
A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client?
- A. Observing the client at regular intervals for opioid addiction.
- B. Encouraging the client to reduce analgesic use and tolerate the pain.
- C. Evaluating pain control at least every 2 hours.
- D. Increasing the amount of morphine if the client does not administer the medication.
Correct Answer: C
Rationale: Regularly evaluating pain control ensures adequate relief while monitoring for side effects, a priority in PCA management.
A client with a spinal cord injury is at risk for pressure ulcers. Which nursing intervention is most effective?
- A. Reposition the client every 4 hours.
- B. Use a foam mattress without a cover.
- C. Apply lotion to bony prominences daily.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning every 2 hours redistributes pressure, preventing ulcer formation in immobilized clients.
When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle?
- A. Dysmenorrhea.
- B. Metrorrhagia.
- C. Oligomenorrhea.
- D. Menorrhagia.
Correct Answer: C
Rationale: Thyrotoxicosis increases metabolism, which can lead to decreased menstrual flow or oligomenorrhea (infrequent menstruation). Dysmenorrhea (painful periods), metrorrhagia (irregular bleeding), and menorrhagia (heavy bleeding) are less commonly associated with thyrotoxicosis.