Nokea
A toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL).
Which of the following nursing actions should have the highest priority?
- A. Keep a tongue blade at the bedside.
- B. Encourage the child to participate in play therapy.
- C. Apply cool soaks to the injection site.
- D. Rotate the injection sites.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no longer used for seizures, but it is important to have seizure precautions and emergency respiratory equipment available (2) important to implement, but is not a priority (3) contains incorrect information (4) correct-highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites
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The nurse is caring for an adult who had a cervical laminectomy this morning. In addition to routine vital signs, what should the nurse assess because of the location of the surgery?
- A. Pedal pulses
- B. Hand grasps
- C. Radial pulse
- D. Urine output
Correct Answer: B
Rationale: Cervical laminectomy affects the cervical spine, which innervates upper extremities; assessing hand grasps evaluates neurological function. Pedal pulses, radial pulse, and urine output are unrelated.
The nurse is assessing the client's abdomen. Which should the nurse do first?
- A. Auscultate
- B. Percuss
- C. Inspect
- D. Palpate
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
A client displaying the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend says she thinks that he has been using hallucinogenic drugs.
The appropriate nursing action would be to
- A. put the client in full restraints.
- B. decrease environmental stimulation.
- C. call the security guards.
- D. administer a PRN dose of chlorpromazine (Thorazine).
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary at this time (2) correct-symptoms will subside with time and decreased stimulation (3) unnecessary at this time (4) inappropriate
The client is to be discharged after passing a uric acid kidney stone. This is the third time the client has been hospitalized for kidney stones. The nurse should teach the client to do which of the following?
- A. Eat generous amounts of chicken and organ meats
- B. Drink lots of water
- C. Avoid vigorous activity
- D. Take the ordered allopurinol (Zyloprim) if the symptoms recur
Correct Answer: B
Rationale: Increased fluid intake (lots of water) prevents stone formation by diluting urine. High-purine foods (meats), activity avoidance, or conditional allopurinol are incorrect.
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.