The nurse is preparing to administer a DTP, Hib, and hepatitis B immunizations to an infant. The nurse should:
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Solution
Answer B is correct. When administering the DTP, Hib, and hepatitis B vaccines, it is recommended that the DTP be administered in one leg and the Hib and hepatitis B vaccine be administered in the other leg. Answer A is incorrect because all the immunizations are not given in one site. No immunizations are to be given in the infant’s arm; therefore, answers C and D are incorrect.
A client with Addison’s disease has a diagnosis of fluid volume deficit related to inadequate adrenal hormone secretion. Which fluids are most appropriate for the client with Addison’s disease?
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Solution
Answer C is correct. The client with Addison’s disease needs an increased sodium intake. Bouillon and juices such as tomato juice are high in sodium. Answers A, B, and D are incorrect because they do not contain high levels of sodium.
A client develops cravings while withdrawing from alcohol. Which measure will best help the client maintain sobriety?
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Solution
Answer C is correct. An established means of dealing with cravings and maintaining sobriety is gaining support from other recovering alcoholics. Answers A and B are incorrect because they are punitive and will not help the client deal with his cravings. Answer D will help provide for the client’s safety during withdrawal, but it will not help the client maintain sobriety; therefore, it is incorrect.
An elderly client injured in a fall is admitted with fractures of the ribs and a closed right pneumothorax. The nurse should position the client:
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Solution
Answer B is correct. Positioning the client in semi-Fowler’s position tilted toward the right side will help to splint the fractured ribs and will allow the uninvolved left lung to fully inflate. Answers A and C are incorrect because they would make breathing more difficult. Answer D is incorrect because it would not allow the full expansion of the uninvolved lung.
Which nursing action is most appropriate immediately following the removal of a nasogastric tube?
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Solution
Answer A is correct. Providing mouth care should be done immediately after the removal of a nasogastric tube. Answers B, C, and D are incorrect because they are done later.
A 40-year-old client with a myocardial infarction tells the nurse, “My father died with a heart attack when he was in his forties, and I guess I will, too.” Which response by the nurse is most appropriate?
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Solution
Answer A is correct. Asking the client to tell more about what he is feeling gives the client an opportunity to discuss his fears and apprehensions. Answer B is incorrect because it is a closed question. Answer C is incorrect because it minimizes the client’s feelings and offers false reassurances. Answer D is incorrect because it minimizes the client’s feelings.
A client with congestive heart failure loses 4.1kg while hospitalized. The client’s weight loss is approximately:
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Solution
Answer D is correct. A weight of 2.2 pounds is equal to 1kg; therefore, 4.1kg equals 9.02kg. Answers A, B, and C are inaccurate answers; therefore, they are incorrect.
The nurse is assessing a client who has undergone a right lobectomy. Which assessment should alert the nurse to the possibility of internal bleeding?
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Solution
Answer C is correct. Signs of possible internal bleeding include restless and shortness of breath. Answer A is incorrect because the urinary output is within normal limits. Answer B is incorrect because the color and rate of chest tube drainage is within the expected range following a lobectomy. Answer D is incorrect because the pulse rate and respiratory rate would be increased with internal bleeding.
Which technique should the nurse use to prevent air from entering the stomach during a nasogastric tube feeding?
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Solution
Answer A is correct. To prevent air from entering the stomach, the nurse should pour all the formula into the syringe barrel before opening the clamp. Answers B, C, and D are incorrect because they do not prevent air from entering the stomach during nasogastric tube feeding.
The physician has ordered Nardil (phenelzine), an MAO inhibitor for a client who is currently taking Paxil (paroxetine). The nurse should:
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Solution
Answer B is correct. The concurrent use of an MAO inhibitor such as Nardil and an SSRI such as Paxil is contraindicated because it can result in serotonin syndrome. Answers A and D are incorrect because the concurrent use of the medications is contraindicated. Answer C is incorrect because anti-Parkinsonian medication is used for the client with neuroleptic malignant syndrome, not serotonin syndrome.