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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Until Mr. Jones’ diagnosis is confirmed, what should be a priority?
- A. Encouraging rest
- B. Monitoring intake and output
- C. Preventing spread of infection to others
- D. Providing attractive meals
Correct Answer: C
Rationale: The correct answer is C: Preventing spread of infection to others. This is the priority because until Mr. Jones' diagnosis is confirmed, it is crucial to prevent potential transmission of any infectious diseases to others. Encouraging rest (choice A) and providing attractive meals (choice D) are important for overall well-being but not as critical as preventing the spread of infection. Monitoring intake and output (choice B) is important for assessing Mr. Jones' health status but does not directly address the potential risk of infecting others. Therefore, choice C is the most immediate priority to ensure the safety of others.
Joan is diagnosed with a ruptured aneurysm. She wonders why this was not picked up in her annual physical. You respond by saying
- A. The physician must have misread the x-ray.
- B. The aneurysm must have developed since the physical.
- C. Aneurysms are often asymptomatic.
- D. Do not be too concerned because this happens all the time.
Correct Answer: C
Rationale: Aneurysms can develop silently without noticeable symptoms.
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.
A client is being treated for inhalational anthrax following bioterrorism exposure. Which of the following medications should NOT be expected as a common treatment for anthrax?
- A. Ciprofloxacin
- B. Doxycycline
- C. Amoxicillin
- D. Penicillin G
Correct Answer: D
Rationale: The correct answer is D, Penicillin G. Anthrax is caused by Bacillus anthracis, which is susceptible to ciprofloxacin and doxycycline. Penicillin and amoxicillin are not recommended due to the potential for B. anthracis to produce beta-lactamase, which can make the bacteria resistant to penicillin-based medications. Penicillin G is not effective in treating anthrax and should not be expected as a common treatment option.
The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.