Nokea
While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:
- A. Stop the medication from infusing
- B. Flush the IV catheter with normal saline
- C. Apply a tourniquet and call the doctor
- D. Continue the IV and assess the site for edema
Correct Answer: A
Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.
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The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?
- A. Treatment is not recommended for children less than 10 years of age.
- B. Bed linens should be washed in hot water.
- C. Medication therapy will continue for 1 year.
- D. Intravenous antibiotic therapy will be ordered.
Correct Answer: B
Rationale: Washing bed linens in hot water helps eliminate lice and nits, which is a key part of treatment for pediculosis capitis.
A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
- A. Your infant is fine. Don't worry.
- B. Apgar scores indicate a need for extra medical care at birth. Your baby's score of 7 is fine.
- C. There are many good special education programs available I can recommend.
- D. I'll ask the physician to speak with you.
Correct Answer: B
Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.
A 51-year-old client received a kidney transplant. Which of the following signs and symptoms indicates possible rejection of the kidney? Select all that apply.
- A. increased urine output
- B. increase in blood pressure
- C. weight gain
- D. pain in lower back
- E. decreased creatinine
Correct Answer: B,C,D
Rationale: Kidney rejection causes hypertension (B), fluid retention (weight gain, C), and graft pain (D). Decreased urine output (not increased) and elevated creatinine (not decreased) are typical.
The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?
- A. Hearing impairment
- B. Cognitive impairment
- C. Vision impairment
- D. Anxiety
Correct Answer: A
Rationale: Staring at the mouth, answering loudly, and misunderstanding questions suggest hearing impairment (A). Cognitive impairment (B), vision impairment (C), and anxiety (D) do not typically present with these specific behaviors.
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.