Nokea
Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?
- A. Client denies allergies to contrast media.
- B. Skin prep to insertion site completed.
- C. On-call sedation administered.
- D. Oxygen at 2 L/minute via nasal cannula.
Correct Answer: C
Rationale: Rationale: Option C, on-call sedation administered, is the correct answer because sedation is essential for bronchoscopy to ensure the client is comfortable and cooperative during the procedure. Sedation helps reduce anxiety and discomfort, making the procedure more tolerable. Options A, B, and D are incorrect as they do not directly indicate readiness for the procedure. Denying allergies to contrast media (A) is important but not specific to bronchoscopy readiness. Skin prep completion (B) is part of the pre-procedure preparation but does not confirm readiness. Oxygen administration (D) is a routine care measure and does not indicate readiness for bronchoscopy.
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When assessing a client reporting severe pain in the right lower quadrant of the abdomen, which sign would most likely indicate appendicitis?
- A. Rebound tenderness at McBurney's point.
- B. Positive Murphy's sign.
- C. Rovsing's sign.
- D. Cullen's sign.
Correct Answer: A
Rationale: The correct answer is A: Rebound tenderness at McBurney's point. McBurney's point is located in the right lower quadrant and is a classic sign of appendicitis. Rebound tenderness at this point indicates inflammation in the peritoneum, suggesting appendicitis. Choices B, C, and D are not specific to appendicitis. Positive Murphy's sign is related to cholecystitis, Rovsing's sign is seen in acute appendicitis but is not as specific as rebound tenderness at McBurney's point, and Cullen's sign is associated with acute pancreatitis.
Following a CVA, the nurse assesses that a client developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?
- A. Continuous tube feeding at 65 ml/hr via gastrostomy.
- B. Total parenteral nutrition to be infused at 125 ml/hour.
- C. Nasogastric tube connected to low intermittent suction.
- D. Metoclopramide (Reglan) intermittent piggyback.
Correct Answer: A
Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. Dysphagia, hypoactive bowel sounds, and a distended abdomen indicate a potential risk for aspiration or impaired gastrointestinal motility. Continuous tube feeding may worsen these conditions. The nurse should question this prescription to prevent further complications. Choices B, C, and D are not immediate concerns for dysphagia and bowel issues. Total parenteral nutrition, nasogastric tube connected to suction, and metoclopramide can be appropriate interventions for nutritional support and bowel motility in this scenario.
A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?
- A. Tardive dyskinesia.
- B. Orthostatic hypotension.
- C. Photosensitivity.
- D. Hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol is a first-generation antipsychotic known to cause extrapyramidal side effects, including tardive dyskinesia, which is characterized by involuntary repetitive movements of the face and body. This side effect is a serious concern due to its potential to be irreversible. Monitoring for tardive dyskinesia is crucial in clients taking haloperidol to detect and manage symptoms promptly.
Explanation for incorrect choices:
B: Orthostatic hypotension - This side effect is more commonly associated with other antipsychotic medications, particularly second-generation ones.
C: Photosensitivity - Haloperidol does not typically cause photosensitivity as a side effect.
D: Hyperglycemia - While some antipsychotic medications may lead to metabolic side effects like hyperglycemia, haloperidol is not typically associated with this specific side effect.
A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct Answer: D
Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.
When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?
- A. Are you allergic to any other medications?
- B. How often have you taken penicillin in the past?
- C. Is anyone else in your family allergic to penicillin?
- D. What happens to you when you take penicillin?
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.