Nokea
Which of the following baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
- A. Potassium level.
- B. Lee-White clotting time.
- C. Hemoglobin level, hematocrit, and platelet count.
- D. Blood glucose level.
Correct Answer: C
Rationale: These tests assess bleeding risk, critical before administering thrombolytics like alteplase, which can cause hemorrhage.
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A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
- A. Nightingale agitation
- B. Extrapyramidal side effects
- C. Vomiting
- D. Anticholinergic side effects
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do which of the following. Select all that apply.
- A. Assure that the oxygen is not blowing directly on the infant’s face.
- B. Place the butterfl y mobile on the outside of the hood.
- C. Immobilize the infant with restraints.
- D. Remove the hood for 10 minutes every hour.
- E. Encourage the parents to visit the child.
Correct Answer: A,B,E
Rationale: When an oxygen hood is used, the nurse should be sure the oxygen source is not directed on the infant’s face to avoid skin irritation. Mobiles can be used to provide visual stimulation, but they should not be placed inside of the hood where they are a potential choking hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the physician has written the order. There should be as little movement in and out of the hood as possible in order to maintain the warm and humid oxygen levels. The nurse should encourage the parents to visit the child and provide verbal and tactile stimulation.
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?
- A. To control bleeding in the bladder.
- B. To instill antibiotics into the bladder.
- C. To keep the catheter free from clot obstruction.
- D. To prevent bladder distention.
Correct Answer: C
Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.
The nurse is assessing teenaged girls at a well child clinic. The nurse should describe the girl shown in the figure as having:
- A. Normal posture
- B. Kyphosis
- C. Scoliosis
- D. Lordosis
Correct Answer: C
Rationale: Scoliosis is characterized by a lateral curvature of the spine, which may be observed in a teenager. Kyphosis involves forward curvature, lordosis involves inward lumbar curvature, and normal posture lacks these abnormalities.
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions is most important?
- A. Avoid swimming alone.
- B. Take medications at bedtime only.
- C. Use a soft toothbrush.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Avoiding swimming alone is critical for safety in epilepsy to prevent drowning during a seizure.