The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30mcg/mL. What is the appropriate nursing action?
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Solution
Answer B is correct. The normal Dilantin level is 10–20mcg/mL. The 30 level exceeds the normal. The appropriate action would be to notify the physician for orders. Answer A would be inappropriate because of the high level. Answers C and D would require an order from the physician.
Which set of vital signs would best indicate an increase in intracranial pressure in a client with a head injury?
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Solution
Answer A is correct. Increased intracranial pressure vital sign changes include an elevated BP with a widening pulse pressure, decreased heart rate, and temperature elevation. Answer C could occur with shock or hypovolemia. Answer B does not correlate with increased ICP. Answer D shows increased intracranial pressure, but not as much as answer A.
A nurse is observing a student perform an assessment. When the student nurse asks the client to “stick out his tongue,” the student is assessing the function of which of the following cranial nerves?
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Solution
Answer D is correct. This cranial nerve deals with the function of the tongue and its movement. Clients can exhibit weakness and deviation with impairment of this cranial nerve. Answers A, B, and C are not tested by this procedure. Cranial nerve I is smell, cranial nerve II is visual, and cranial nerve X deals with the gag reflex.
A nurse is working in a nursing home and evaluating temperatures that have been recorded by the nurse’s assistant. A temperature of 100.4°F is noted. Which of these responses should the nurse take?
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Solution
Answer B is correct. Any abnormal temperature should be reassessed in 30 minutes. A temperature above 101°F requires that the physician be notified, which makes answer D incorrect. Answer A would be done, but it would not be the only action. Answer C is incorrect because the nurse should wait 5 minutes after food or liquids to retake the temperature, for an accurate recording.
The nurse has reinforced teaching to a client who is on isoniazid (INH). Which diet selection would let the nurse know that the teaching has been ineffective?
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Solution
Answer A is correct. Clients who are taking INH should avoid tuna, red wine, soy sauce, and yeast extracts because of the side effects that can occur, such as headaches and hypotension. Answers B, C, and D are all allowed with this drug.
The nurse is caring for a client after a tracheostomy procedure. The client is anxious, with a respiratory rate of 32 and an oxygen saturation of 88. The nurse’s first action should be to:
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Solution
Answer A is correct. Obstruction of the tracheostomy can cause anxiety, increased respiratory rate, and a decrease in O2 saturation. The nurse should first suction the client. If this doesn’t work, she should notify the physician, as in answer C. Answer B would not help the client’s breathing. Answer D would be done to assess for improvement after the suctioning was performed.
A client with hepatitis C is about to undergo a liver biopsy. Which of the following would the nurse expect to reiterate to this client?
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Solution
Answer C is correct. There is a risk of bleeding with this procedure; therefore, laboratory tests are done to determine any problems with coagulation before the test. Answers A, B, and D are incorrect statements. The client lies on the right side, not the left; no enemas are given; and the test is invasive and can cause some pain.
What is the action of the nurse who assesses dehiscence of a clients’ surgical wound?
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Solution
Answer B is correct. When dehiscence and/or evisceration of a wound occurs, the nurse should apply a sterile saline dressing before notifying the physician. Answer A is not the appropriate position because the client should be placed in low Fowler’s position. Answers C and D are not appropriate actions.
The nurse is caring for a client who is nauseated and in danger of aspiration. Which action would the nurse take first?
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Solution
Answer C is correct. Turning the client to the side will allow any vomit to drain from the mouth and decrease the risk for aspiration. Answers A, B, and D are all appropriate as nursing interventions, but a patent airway and prevention of aspiration is the priority.
Which medication is important to have available for clients who have received Versed?
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Solution
Answer C is correct. Versed is used for conscious sedation and is an antianxiety agent. The antidote for this drug is Romazicon, a benzodiazepine. Answers A, B, and D are not utilized as antagonists for Versed; however, answer B is the antagonist for narcotics.