Nokea
A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability.
Which of the following nursing actions is MOST appropriate?
- A. Decrease external stimuli in the child's room.
- B. Administer an analgesic as ordered.
- C. Notify and advise the physician of the child's status.
- D. Document the assessments and continue to observe.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may help the client to cope with current symptoms, but is not highest priority (2) will mask the signs of toxicity (3) correct-signs of toxicity need to be reported to the physician (4) does not take action to resolve the problem
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A young adult is admitted with a diagnosis of Guillain-Barré syndrome. Which nursing action will be of highest priority as the nurse plans care?
- A. Range-of-motion exercises
- B. Monitor respirations
- C. Turn every two hours
- D. Provide emotional support
Correct Answer: B
Rationale: Guillain-Barré syndrome can cause ascending paralysis, risking respiratory muscle weakness; monitoring respirations is critical to detect respiratory failure early.
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission?
- A. A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago
- B. A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24 hours ago
- C. An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning
- D. An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago
Correct Answer: A
Rationale: The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client in option A is most likely stable and could continue medication therapy at home.
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?
- A. Heart rate
- B. Neurologic status
- C. Urine output
- D. Blood pressure
Correct Answer: D
Rationale: The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.
Which finding indicates a need for further assessment of the client scheduled for a magnetic resonance imaging?
- A. The client is an insulin-dependent diabetic.
- B. The client refuses a corner bed.
- C. The client is allergic to shellfish.
- D. The client has a history of asthma.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for MRI contrast dye, requiring further assessment. Diabetes , bed preference , and asthma are not contraindications.
The nurse is caring for a client who has a cervical radioactive implant. Which action is not appropriate for the nurse when caring for this client?
- A. Post a radioactive symbol on the client's chart and on the door to the room.
- B. Put on gloves to remove any radioactive implant that may have come out.
- C. Wash hands with soap and water after caring for the client.
- D. Limit the amount of time with the client.
Correct Answer: B
Rationale: Removing a radioactive implant requires specialized handling, not just gloves, to avoid exposure, making this action inappropriate.