Nokea
When monitoring an infant with a left-to-right sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply.
- A. Clubbing of fingertips
- B. Cyanosis when crying
- C. Diaphoresis during feedings
- D. Heart murmur
- E. Poor weight gain
Correct Answer: C,D,E
Rationale: Left-to-right shunts (e.g., VSD) cause pulmonary overcirculation, leading to diaphoresis, murmurs, and poor weight gain. Clubbing and cyanosis are more typical of right-to-left shunts.
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The nurse is preparing to administer preoperative medication of meperidine and atropine to an elderly adult who is scheduled for surgery. The client tells the nurse that he has glaucoma and wants to take his eye drops before going to the operating room. What is the best action for the nurse to take?
- A. Administer medication as ordered and encourage the client to take his eye drops
- B. Check with the physician before administering preoperative medication
- C. Administer preoperative medication as ordered and suggest the client not take his eye drops
- D. Administer the meperidine, withhold atropine, and suggest the client take his eye drops
Correct Answer: B
Rationale: Atropine, an anticholinergic, can increase intraocular pressure, exacerbating glaucoma. Checking with the physician ensures safe administration, as withholding atropine or adjusting eye drop use may be necessary.
A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:
- A. Projection
- B. Displacement
- C. Undoing
- D. Compensation
Correct Answer: B
Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.
The nurse is assessing a client who had a thyroidectomy 12 hours ago and is reporting anxiety, tingling around the mouth, and muscle twitching in the hand. Which of the following actions would be a priority for the nurse to take?
- A. Check the area around the incision site for edema
- B. Review the client’s most recent arterial blood gas results
- C. Evaluate the client’s vocal quality and strength
- D. Obtain a blood specimen to check the serum calcium level
Correct Answer: D
Rationale: Anxiety, tingling, and twitching suggest hypocalcemia from parathyroid damage during thyroidectomy, requiring urgent calcium level assessment. Edema, blood gases, and vocal quality are less urgent.
The nurse is providing pin site care for an adult who is in skeletal traction. What should the nurse do when providing pin site care?
- A. Clean the pin site with alcohol
- B. Clean the pin site with hydrogen peroxide
- C. Clean the pin site with betadine and apply steroid ointment as ordered
- D. Clean the pin site with soap and water and apply antibiotic ointment as ordered
Correct Answer: D
Rationale: Pin site care involves cleaning with soap and water to prevent infection and applying antibiotic ointment as ordered to reduce bacterial growth, per standard protocols.
A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Administer oxygen via non-rebreather mask
- B. Apply an occlusive dressing over the insertion site
- C. Assist the client to high Fowler position
- D. Monitor vital signs and respiratory effort
- E. Notify the health care provider
Correct Answer: A,B,D,E
Rationale: Oxygen, occlusive dressing, vital sign monitoring, and provider notification address air embolism risk and hypoxia. High Fowler may worsen air entry; semi-Fowler is preferred.