Nokea
Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?
- A. Benzodiazepines
- B. Chlorpromazine (Thorazine)
- C. Succinylcholine (Anectine)
Correct Answer: C
Rationale: Succinylcholine (Anectine). Succinylcholine is given intravenously to promote skeletal muscle relaxation.
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The nurse is talking with a client with unilateral facial paralysis. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I may chew food on either side of my mouth because it does not hurt
- B. I need to use my fingers to close my eyelid after instilling eye drops
- C. I should prepare meals that include soft, high-calorie foods
- D. I will place tape on my affected eyelid before I go to sleep
- E. I will put ice on the affected side of my face when it hurts
Correct Answer: A,E
Rationale: Chewing on the affected side risks injury due to impaired sensation, and ice may worsen symptoms in conditions like Bell’s palsy. Closing the eyelid, taping at night, and soft foods are appropriate for facial paralysis management.
Which symptom is considered an adverse reaction to Kantrex (kanamycin)?
- A. Diminished hearing
- B. Hypotension
- C. Hepatomegaly
- D. Petechiae
Correct Answer: A
Rationale: Kanamycin, an aminoglycoside, is ototoxic, and diminished hearing is a known adverse reaction requiring monitoring.
When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?
- A. Have respiratory support equipment available
- B. Administer an antiemetic medication
- C. Monitor the client’s temperature closely
- D. Administer an antihistamine
Correct Answer: A
Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.
A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?
- A. Have the client remove the existing dressing while the nurse prepares sterile supplies
- B. Wear clean gloves for removal and application of a new dressing
- C. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing
- D. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing
Correct Answer: C
Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.
The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in
- A. Calcium
- B. Fiber
- C. Sodium
- D. Carbohydrate
Correct Answer: C
Rationale: Sodium. The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.