Nokea
Which nurse should be assigned to care for the postpartal client with preeclampsia?
- A. The RN with 2 weeks of experience in postpartum
- B. The RN with 3 years of experience in labor and delivery
- C. The RN with 10 years of experience in surgery
- D. The RN with 1 year of experience in the neonatal intensive care unit
Correct Answer: B
Rationale: The RN with labor and delivery experience is best equipped to manage preeclampsia complications in a postpartal client.
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Which of the following tasks are appropriate for the nurse to delegate to unlicensed assistive personnel? Select all that apply.
- A. Checking temperature and vital signs for a client acutely ill with sepsis.
- B. Checking routine temperature and vital signs for clients at the beginning of the shift.
- C. Emptying catheter bags and measuring the urinary output from Foley catheters.
- D. Monitoring the transfusion of red blood cells.
- E. Assisting an ambulatory client to walk to the bathroom.
Correct Answer: B,C,E
Rationale: Unlicensed assistive personnel can perform routine tasks like checking routine vital signs (B), measuring urinary output (C), and assisting with ambulation (E). Checking vital signs in an acutely ill client (A) and monitoring a transfusion (D) require a nurse's assessment skills.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
- A. confused with cold, clammy skin and a pulse of 110.
- B. lethargic with hot, dry skin and rapid, deep respirations.
- C. alert and cooperative with a BP of 130/80 and respirations of 12.
- D. short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL
The physician has ordered sublingual nitroglycerin for a client. Which of the following are contraindications for administration of sublingual or buccal medications? Select all that apply.
- A. Client is edentulous.
- B. Client has mild dementia.
- C. Mucous membranes are red and irritated.
- D. Client is dehydrated.
- E. Client has productive aphasia.
Correct Answer: C,D
Rationale: Red, irritated mucous membranes (C) and dehydration (D) impair sublingual absorption. Edentulous state (A), mild dementia (B), and aphasia (E) do not contraindicate sublingual administration.
A client who has been diagnosed with lung cancer is starting a smoking-cessation program. Which of the following drugs would the nurse expect to be included in the program's plan?
- A. Bupropion SR (Zyban)
- B. Metoproterenol (Alupent)
- C. Oxitropium (Oxivent)
- D. Alprazolam (Xanax)
Correct Answer: A
Rationale: Bupropion SR (Zyban) is commonly used in smoking cessation programs to reduce nicotine cravings and withdrawal symptoms.
A child with achondroplasia will likely have which of the following physical characteristics?
- A. alopecia, failure to thrive, small face, recessed jaw
- B. enlarged hands and feet, skull expansion at fontanelle, enlarged tongue
- C. poor muscle tone, slanted eyes, single palmar crease
- D. dwarf stature, short fingers and toes, short proximal limbs
Correct Answer: D
Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.