The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
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Solution
Hallucinogenic drugs induce a state of altered perception.
Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answers A, C, and D are incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. However, they do produce psychological dependence rather than physical dependence.
A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?
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Solution
Morphine 8 mg IM q 4 hours PRN pain
Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphincter of Oddi. Meperidine, Mylanta, and Cimetidine are ordered for pancreatitis, making answers A, B, and C incorrect.
Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
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Solution
Take prescribed anti-inflammatory medications with meals.
Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Answers A, C, and D are incorrect. Clients with rheumatoid arthritis should exercise, but not to the point of pain. Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Weight-bearing activities such as walking are useful but is not the best answer for the stem.
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
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Solution
Ampicillin
Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propranolol, or Verapamil. There is no indication for an antibiotic such as Ampicillin, so answers A, C, and D are incorrect.
The client with varicella will most likely have an order for which category of medication?
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Solution
Antivirals
Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants as stated in answers A and D. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer B is incorrect.
A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
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Solution
Alteration in coping related to pain
Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers C and D incorrect.
A full-term male has hypospadias. Which statement describes hypospadias?
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Solution
The urethral meatus opens on the underside of the penis.
Hypospadias is a congenital abnormality in which the urethral meatus is on the underside of the penis.
A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
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Solution
Measures the activity of the fetus
A nonstress test is done to evaluate periodic movement of the fetus. It is not done to evaluate lung maturity as in answer A. An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus, so answers C and D are incorrect.
An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
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Solution
24 pounds
By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C are incorrect because they are too low.
A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:
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Solution
Increasing fluid intake
Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for 8 hours. Therefore, answers B, C, and D are incorrect.