Nokea
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. Sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: The correct answer is 0.9% sodium chloride. Normal saline is 0.9% sodium chloride, which has the same osmolarity as blood and does not cause cell lysis. Choices 2 and 3, 5% dextrose in water solution and sterile water, are hypotonic solutions that can lead to cell lysis. Choice 4, Heparin sodium, is an anticoagulant and is not routinely used to flush an IV device before and after the administration of blood.
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The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
- A. The client receiving linear accelerator radiation therapy for lung cancer
- B. The client with a radium implant for cervical cancer
- C. The client who has just been administered soluble brachytherapy for thyroid cancer
- D. The client who returned from placement of iridium seeds for prostate cancer
Correct Answer: A
Rationale: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is the correct choice because the radiation stays in the department, and the client is not radioactive. Choices B, C, and D involve clients who are radioactive or pose a risk due to radioactivity. The client with a radium implant for cervical cancer (choice B) is radioactive, the client who has just been administered soluble brachytherapy for thyroid cancer (choice C) is radioactive for approximately 72 hours, and the client who returned from placement of iridium seeds for prostate cancer (choice D) is also radioactive, especially right after the procedure. These options are not suitable for assignment to the pregnant nurse.
An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?
- A. knowledge that elder abuse is rare
- B. personal belief that abuse is deserved
- C. lack of developmentally appropriate screening tools
- D. fear of reprisal or further violence if the incident is reported
Correct Answer: D
Rationale: Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser. Choice A is incorrect because knowledge of the frequency of elder abuse is not a significant factor in a victim's reluctance to report. Choice B is also incorrect; while some victims may have feelings of undeservedness, it is not a common primary barrier to reporting abuse. Choice C is incorrect as the lack of appropriate screening tools may hinder identification but is not a significant barrier for the client to admit being a victim. Therefore, the correct answer is D, as the fear of reprisal or further violence if the incident is reported is a common and significant barrier for elderly clients to admit being a victim.
Following the change of shift report, when can or should the nurse alter or modify the plan?
- A. halfway through the shift
- B. at the end of the shift before handing over
- C. when needs change
- D. after the top-priority tasks have been completed
Correct Answer: C
Rationale: The correct answer is 'when needs change.' The nurse should be flexible and adjust the plan as necessary when the needs of the patients change. This ensures that care is provided effectively and efficiently. Choices A, B, and D are incorrect because altering the plan based on time intervals, solely at the end of the shift, or after completing top-priority tasks may not align with the current needs of the patients.
After a client undergoes a left lower lobe lung resection for lung cancer, which post-operative measure would typically be included in the plan?
- A. Closed chest drainage
- B. A tracheostomy
- C. A mediastinal tube
- D. Percussion vibration and drainage
Correct Answer: A
Rationale: After a lung resection, such as the removal of the left lower lobe for lung cancer, closed chest drainage is a common post-operative measure to help drain any excess air or fluid from the chest cavity. A tracheostomy is not typically needed for this procedure, so choice B is incorrect. Similarly, a mediastinal tube is not routinely inserted following a left lower lobe lung resection, making choice C incorrect. Percussion vibration and drainage are not indicated for this type of surgery, so choice D is also incorrect. Therefore, the correct answer is closed chest drainage.
The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?
- A. Tinnitus
- B. Persistent cough
- C. Muscle weakness
- D. Diarrhea
Correct Answer: B
Rationale: A persistent cough might be related to an adverse reaction to captopril (Capoten). Tinnitus (choice A) and diarrhea (choice D) are not commonly associated adverse reactions of captopril. Muscle weakness (choice C) might occur initially but is not considered a common adverse effect of captopril. Therefore, the correct answer is B, persistent cough, as it is a known adverse reaction to captopril.