Nokea
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
- A. A percutaneous, non tunneled subclavian catheter
- B. A peripheral intravenous catheter that is 20 gauge
- C. A multi lumen implanted tunneled and cuffed central venous catheter
- D. A peripherally inserted central venous catheter
Correct Answer: C
Rationale: A multi-lumen implanted tunneled and cuffed central venous catheter is most appropriate for long-term IV therapy, blood products, and hyperalimentation due to its durability and reduced infection risk.
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A client with a history of type 2 diabetes mellitus is prescribed liraglutide (Victoza). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Liraglutide can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:
- A. Methylphenidate (Ritalin).
- B. Lorazepam (Ativan).
- C. Nefazodone (Serzone).
- D. Sertraline (Zoloft).
Correct Answer: B
Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.
Select the legal term that is accurately paired with its description.
- A. Assault: Touching a person without their consent
- B. Battery: Threatening to touch a person without their consent
- C. Slander: False oral defamatory statements.
- D. Slander: False written defamatory statements.
Correct Answer: C
Rationale: Slander is correctly defined as false oral defamatory statements. Assault is threatening harm , battery is unauthorized touching , and libel is false written defamation .
The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:
- A. Relief from spasms of the diaphragm.
- B. Relaxation of smooth muscles in the bronchioles.
- C. Efficient pulmonary circulation.
- D. Stimulation of the medullary respiratory center.
Correct Answer: B
Rationale: Aminophylline, a bronchodilator, is effective when it relaxes bronchial smooth muscles, improving airflow in emphysema.
A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.