Nokea
Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis.
- B. It minimizes the risk of pulmonary embolism.
- C. It minimizes the risk of circulatory overload.
- D. It minimizes the risk of localized edema.
Correct Answer: B
Rationale: The correct answer is B because dislodged catheters can lead to emboli formation.
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The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus.
- B. Opening the bottom of the pouch, allowing the flatus to be expelled.
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape.
- D. Assisting the client to ambulate to reduce the flatus in the pouch.
Correct Answer: B
Rationale: Opening the bottom of the pouch allows controlled release of flatus.
What causes an audible wheeze in Mr. Ross’ right lung?
- A. Inflammation of pleural surfaces
- B. Obstruction of the bronchus
- C. Collection of exudate in the pleural cavity
- D. Dilatation of the alveoli
Correct Answer: B
Rationale: Bronchial obstruction leads to turbulent airflow, producing wheezing.
The patient experiences sudden pain in his right calf while sitting at home. He is diagnosed with deep vein thrombosis (DVT). The first intervention is to
- A. Apply ice packs to the affected area every 4 to 6 hours.
- B. Increase dietary intake of foods rich in vitamin K.
- C. Monitor platelet counts daily.
- D. Use intermittent warm soaks of the affected area.
Correct Answer: C
Rationale: Monitoring platelets is crucial when anticoagulants are administered.
Mr. Johnstone is treated for removal of foreign bodies in both eyes and is discharged with patches on both eyes. In teaching Mr. Johnstone's family to assist him in walking, the nurse advises the family member to
- A. grasp him by the arm and walk behind him
- B. grasp him by the arm and walk in front of him
- C. offer your arm and walk in front of him
- D. offer your arm and walk behind him
Correct Answer: C
Rationale: Offering an arm and walking slightly ahead provides guidance and support while allowing the visually impaired person to follow safely.
What should the nurse do if Wendy develops moderate hypotension and irregular pulse while receiving aminophylline?
- A. Check apical pulse and blood pressure every 10 minutes and continue present aminophylline administration
- B. Discontinue the aminophylline drip and call the physician
- C. Rapidly administer epinephrine 1:1000 intravenously
- D. Slow the rate of aminophylline administration, monitor vital signs, and notify physician
Correct Answer: D
Rationale: Adjusting the infusion rate prevents further adverse effects.