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 tunneled and cuffed central venous catheter is ideal for long-term therapy due to its durability and lower infection risk.
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The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
- A. A bulging anterior fontanel
- B. An elevated apical heart rate
- C. The presence of protein in the urine
- D. A drop in blood pressure from baseline
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.
The nurse is caring for a client who has just undergone a nephrectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor urine output.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: A
Rationale: Monitoring urine output is critical post-nephrectomy to assess the function of the remaining kidney.
A client with a history of stroke is at risk for aspiration. Which intervention is most appropriate?
- A. Offer thin liquids.
- B. Position upright during meals.
- C. Provide large bites of food.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk by aiding swallowing and gravity.
A client has had sucralfate (Carafate) ordered as treatment for peptic ulcer disease. Which of the following statements indicates that the client understands how to take the medication?
- A. I should take the Carafate every evening at bedtime.'
- B. It is important that I take this drug on an empty stomach.'
- C. I should avoid milk products while taking this drug.'
- D. I should have my hemoglobin checked monthly while taking Carafate.'
Correct Answer: B
Rationale: Sucralfate should be taken on an empty stomach to coat the stomach lining effectively. Bedtime dosing, avoiding milk, or monthly hemoglobin checks are not required.
The nurse should consider which of the following principles when developing a plan of care to manage a client's pain from cancer?
- A. Individualize the pain medication regimen for the client.
- B. Select medications that are least likely to lead to addiction.
- C. Administer pain medication as soon as the client requests it.
- D. Change pain medications periodically to avoid drug tolerance.
Correct Answer: A
Rationale: Individualizing the regimen ensures effective pain control tailored to the client's needs, considering cancer pain's variable nature.