Nokea
Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
- A. Assisting with a naloxone challenge test before therapy begins
- B. Discontinuing the drug immediately if signs of dependence appear
- C. Changing the administration route to P.O. if the client can tolerate fluids
- D. Obtaining baseline vital signs before administering the first dose
Correct Answer: D
Rationale: Obtaining baseline vital signs before administering the first dose is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine. Monitoring vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is essential to assess the client's response to opioid therapy. Baseline vital signs provide a comparison for evaluating changes in the client's physical status and help identify any adverse effects or complications related to morphine administration. This proactive approach allows the nurse to detect and address any abnormalities promptly, ensuring the client's safety and optimal pain management.
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A 5-year old boy presents with afebrile generalized tonic-clonic seizure lasting for 5 minutes. Previously he was healthy and had no such problem. On examination there is no abnormality. Your plan of management should be:
- A. Start anticonvulsant therapy
- B. Request for an EEG and wait for its report
- C. Request for an EEG and start anticonvulsant therapy immediately
- D. Request for EEG and MRI brain
Correct Answer: C
Rationale: In a first-time generalized seizure, an immediate EEG and starting anticonvulsant therapy is prudent to prevent recurrence, especially if the EEG shows epileptiform activity.
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client's temperature before, during, and after transfusion
- B. Documenting the client's temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client's temp with the temp of the blood
Correct Answer: A
Rationale: Monitoring the client's temperature before, during, and after transfusion is essential to determine if chilling is the result of an emerging complication or of infusing cold blood. By consistently monitoring the client's temperature at different points in the transfusion process, healthcare providers can identify any significant changes that may indicate a complication. This allows for timely intervention and appropriate management of any issues related to the blood transfusion. Comparing the client's temperature with the temperature of the blood is important but alone it may not provide a comprehensive assessment of the client's condition during the transfusion process. So, the best course of action is to monitor the client's temperature at various time points to ensure accurate assessment and early detection of any complications.
A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
- A. The client has no previous exposure to the antigens injected
- B. The results demonstrate the client has antibodies to the antigens
- C. The client is immunodeficient and won't have a skin response
- D. The client isn't allergic to the antigens and therefore doesn't react
Correct Answer: C
Rationale: A client with HIV undergoing intradermal anergy testing with Candida and mumps antigens is suspected to be immunodeficient, making them unable to mount a normal skin response to these antigens. In an immunodeficient individual, the immune system is weakened, leading to a lack of response when exposed to these antigens. A lack of induration or reaction in the 3 days following the test suggests that the client's immune system is not able to mount a normal response, indicating immunodeficiency. The absence of a reaction does not necessarily indicate lack of exposure (Option A), presence of antibodies (Option B), or the absence of allergies (Option D), but rather points to a compromised immune system in an individual with HIV.
the best prophylactic treatment to prevent further rheumatic fever attack:
- A. prednisone
- B. aspirin
- C. penicillin
- D. paracetamol
Correct Answer: C
Rationale: The best prophylactic treatment to prevent further rheumatic fever attacks is penicillin. Penicillin is recommended for long-term secondary prophylaxis to prevent the recurrence of acute rheumatic fever and reduce the risk of rheumatic heart disease. It helps to eradicate streptococcal infections, which are the underlying cause of rheumatic fever. Prednisone, aspirin, and paracetamol are not used for primary or secondary prevention of rheumatic fever.
An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: When an adult is on a clear liquid diet, foods that are easy to digest and leave little residue in the gastrointestinal tract are recommended. Clear liquids include water, broth, fruit juices without pulp, and gelatin desserts like Jello. Jello is a good option because it is easily digestible, does not leave residue, and provides some calories and hydration. Milk, orange juice, and ice cream should be avoided on a clear liquid diet as they are not considered clear liquids and may not be as easily digestible.