Nokea
The nurse is assigned to a patient newly diagnosed with active tuberculosis.
Which of these interventions would be a priority for the nurse to implement?
- A. Have the client cough into a tissue and dispose in a separate bag
- B. Instruct the client to cover the mouth with a tissue when coughing
- C. Reinforce that everyone should wash their hands before and after entering the room
- D. Place client in a negative pressure private room and have all who enter the room use masks with shields
Correct Answer: D
Rationale: A negative pressure room and masks prevent airborne transmission of tuberculosis, a priority for infection control.
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A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
- A. Decreased level of consciousness (LOC)
- B. Elevated blood pressure
- C. Increased urine output
- D. Decreased heart rate
Correct Answer: C
Rationale: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
- A. Apply cool soaks and keep the client's leg lower than the level of the heart
- B. Increase the client's activity level and encourage leg exercises
- C. Apply cool soaks and administer nitroglycerin
- D. Apply warm soaks and elevate the client's legs higher than the level of the heart
Correct Answer: D
Rationale: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.
Ms. L had a C-section done. She delivered a healthy baby boy. On her 1st post operative day, Ms. L's roommate called the nurse & reports that Ms. L was very anxious & pale looking. Other clients were in Ms. L's room trying to help out. Upon assessment, her BP was 80/60, HR 110bpm.
The top nursing priority includes:
- A. monitor the patient's v/s & notify the doctor stat
- B. Clear the patient's immediate environment & ask other clients to move away
- C. Place the patient in flat position and check her abdominal dressing.
- D. Get the crash cart in anticipation for cardiac arrest
Correct Answer: A
Rationale: Hypotension and tachycardia suggest postpartum hemorrhage, requiring immediate physician notification.
A patient with a history of myocardial infarction is prescribed aspirin. Which of the following instructions should the nurse include?
- A. Take this medication on an empty stomach.
- B. Avoid taking this medication with other NSAIDs
- C. Discontinue the medication if you experience ringing in your ears.
- D. Take this medication only when you have chest pain.
Correct Answer: B
Rationale: Avoiding other NSAIDs prevents increased bleeding risk with aspirin, a key antiplatelet post-MI. Empty stomach increases GI upset, ringing requires reporting, and aspirin is daily, not PRN.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck. The nurse would expect to give which of the following as a PRN medication?
- A. Promazine (Sparine).
- B. Biperiden (Akineton).
- C. Thiothixene (Navane).
- D. Haloperidol (Haldol).
Correct Answer: B
Rationale: The symptoms describe acute dystonia, an extrapyramidal side effect of perphenazine. Biperiden, an antiparkinsonian agent, counteracts these effects. Promazine, thiothixene, and haloperidol (A, C, D) are antipsychotics and would not relieve dystonia.