Nokea
A patient is returned from surgery with a Jackson-Pratt drain in place. The nurse observes a student nurse perform a dressing change for the patient.
Which of the following activities if performed by the student nurse would require an intervention by the nurse?
- A. Documents the amount and character of the drainage in the patient's chart.
- B. Attaches the drain to the top sheet on the bed.
- C. Empties the reservoir of the drain.
- D. Records the amount of drainage on the output sheet.
Correct Answer: B
Rationale: Strategy: 'Require an intervention' indicates an incorrect response. (1) drains used to prevent wound infections and abscess formation (2) correct-drain should be attached to patient's gown or pajamas, never to the sheet or mattress (3) Jackson-Pratt drain is a self-contained suction device that is emptied as needed (4) important to monitor output
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The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I'll take this pill with meals and before bed.
- B. I may experience mild diarrhea for a while.
- C. My stools may change color while I'm on this medication.
- D. I should call my doctor if I get an acne-like rash.
Correct Answer: C
Rationale: no change in stool color
A client with a statement indicating the use of a defense mechanism.
Which of the following statements, if made by a client to the nurse, would indicate that the client is using the defense mechanism of conversion?
- A. I love my family with all my heart even though they don't love me.'
- B. I was unable to take my final exams because I was unable to write.'
- C. I don't believe I have diabetes. I feel perfectly fine.'
- D. If my wife was a better housekeeper I wouldn't have such a problem.'
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates reaction formation (2) correct-client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform (3) indicates denial (4) indicates projection
The nurse cares for an 8 lb, 8 oz newborn boy. The infant's history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed?
- A. Temperature 97.6°F (36.5°C).
- B. Apical pulse 140 bpm.
- C. Respirations 18.
- D. BP 80/50.
Correct Answer: C
Rationale: magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min
An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should
- A. warm the irrigating solution to 110°F (43.3°C).
- B. establish a sterile field that includes the irrigating equipment.
- C. direct the irrigating solution at the outer edges of the wound, then the center of the wound.
- D. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.
Correct Answer: B
Rationale: requires strict aseptic technique