Nokea
Which intervention is contraindicated for a client with a seizure disorder?
- A. Provide a safe environment.
- B. Use a padded tongue depressor.
- C. Administer prescribed anticonvulsants.
- D. Monitor post-seizure status.
Correct Answer: B
Rationale: Using a padded tongue depressor is contraindicated as it can cause injury during a seizure.
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The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication?
- A. 19 gauge, 1 1/2" (3.8 cm) needle
- B. 18 gauge, 1" (2.5 cm) needle
- C. 20 gauge, 1" (2.5 cm) needle
- D. 25 gauge, 5/8" (1.6 cm) needle
Correct Answer: D
Rationale: A 25-gauge, 5/8" needle is appropriate for neonates due to their small muscle mass and thin subcutaneous tissue, minimizing trauma.
A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following?
- A. Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient.
- B. Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion.
- C. Febrile reactions are rarely immune-mediated and can be a sign of hemolytic transfusion.
- D. Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and can occur during the blood transfusion.
Correct Answer: B
Rationale: Febrile reactions can often be prevented with premedication like antipyretics and antihistamines, which is a reassuring and accurate response for the client.
Which activity should a client with an ileal conduit avoid?
- A. Swimming.
- B. Walking.
- C. Heavy lifting.
- D. Reading.
Correct Answer: C
Rationale: Heavy lifting can strain the stoma site, increasing hernia risk.
The client tells the preoperative nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response?
- A. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken.
- B. Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.
- C. Explain to the client that she will have a premedication that will make her sleep before she goes to surgery and she won't need to hear.
- D. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.
Correct Answer: D
Rationale: Calling the surgery unit to discuss the client's need for a hearing aid ensures her communication needs are addressed while adhering to surgical safety protocols. This action balances patient advocacy with policy considerations.
A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. In which position are his feet if he is complying with his postoperative instructions?
- A. On the floor with the feet flat.
- B. On a low footstool.
- C. In any comfortable position with legs uncrossed.
- D. On a high footstool so the feet are level with the chair seat.
Correct Answer: A
Rationale: Feet flat on the floor maintain neutral spine alignment, reducing strain on the surgical site.