Nokea
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow immediately halts the administration of the allergen, which is the priority in anaphylaxis.
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A client who has been taking diazepam (Valium) for 3 months for skeletal muscle spasms and the patient was a secret agent to the medication and the medication days ago because it was no longer helping him, but now he feels terrible. The nurse should assess the client for which of the following? Select all that apply.
- A. Insomnia.
- B. Euphoria.
- C. Bradycardia.
- D. Diaphoresis.
- E. Tremor.
- F. Vomiting.
Correct Answer: A, D, E, F
Rationale: Abrupt cessation of diazepam can cause withdrawal symptoms like insomnia, diaphoresis, tremor, and vomiting.
A nurse is assessing an 82-year-old for depression, because of the client's age, the nurses' assessment should be guided by the fact that:
- A. Sadness of mood is usually present but it is masked by other symptoms.
- B. Impairment of cognition usually is not present.
- C. Psychosomatic tendencies do not tend to dominate.
- D. Antidepressant therapies are less effective in older adults.
Correct Answer: A
Rationale: In older adults, depression may present with atypical symptoms, such as somatic complaints or irritability, rather than overt sadness, which can mask the condition.
A client with a history of rheumatoid arthritis is prescribed hydroxychloroquine (Plaquenil). The nurse should instruct the client to:
- A. Have regular eye exams.
- B. Take the medication on an empty stomach.
- C. Avoid calcium-rich foods.
- D. Stop the medication if joint pain resolves.
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams.
A 6-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The child asks the nurse if the cardiac catheterization will hurt. Which of the following statements offers the nurse the best guide for responding to the child's question?
- A. The medication used to numb the insertion site will sting
- B. Momentary sharp pain usually occurs when the catheter enters the heart
- C. It is usual for a 6-year-old to feel discomfort during the procedure
- D. It is a painless procedure, although a tingling sensation may be felt in the extremities
Correct Answer: A
Rationale: The local anesthetic used at the insertion site for cardiac catheterization may cause a stinging sensation, which is an honest and appropriate response for a 6-year-old. Pain is not typically felt when the catheter enters the heart, and discomfort or tingling is not a standard experience.
A client with chronic kidney disease is on a low-potassium diet. Which of the following foods should the nurse recommend?
- A. Bananas
- B. Apples
- C. Oranges
- D. Potatoes
Correct Answer: B
Rationale: Apples are low in potassium, suitable for a renal diet. Bananas, oranges, and potatoes are high in potassium and should be avoided.