Nokea
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent episodes of alertness
Correct Answer: D
Rationale: A preschooler with intermittent episodes of alertness. A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump.
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The nurse educator is focusing on the prevention of infection. Place an X on the illustration that displays the best measure to prevent infection when caring for clients on a nursing unit?
- A. infection_1.PNG
- B. infection_2.PNG
- C. infection_3.PNG
- D. infection_4.PNG
- E. infection_5.PNG
Correct Answer: A
Rationale: A: Hand hygiene is the most effective measure to prevent infection transmission. Other measures like isolation or gloves are situational, but hand washing is universally critical.
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the dorsal gluteal site
- C. call to get a smaller volume ordered
- D. check with pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: administer the medication in 2 separate injections. Intramuscular injections should not exceed a volume of 1 ml for small children. Medication doses exceeding this volume should be split into 2 separate injections of 1.0 ml each. In adults the maximum intramuscular injection volume is 5 ml per site.
The nurse is caring for a client with clinical depression who is receiving a monoamine oxidase inhibitor (MAOI). When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?
- A. Avoid chocolate and cheese
- B. Take frequent naps
- C. Take the medication with milk
- D. Avoid walking without assistance
Correct Answer: A
Rationale: Avoid chocolate and cheese. Foods high in tryptophan, tyramine, and caffeine, such as chocolate, wine, and cheese may precipitate hypertensive crisis.
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
- A. Pallor
- B. Increased temperature
- C. Dyspnea
- D. Involuntary muscle spasms
Correct Answer: C
Rationale: Dyspnea. Clients having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be to
- A. cover the areas with dry sterile dressings
- B. assess for dyspnea or stridor
- C. initiate intravenous therapy
- D. administer pain medication
Correct Answer: B
Rationale: assess for dyspnea or stridor. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.