A client is to undergo a bone marrow aspiration. The nurse plans to include which statement in the client preparation?
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Solution
Answer B is correct. There will be a sensation of pulling during the aspiration. This feeling is painful. Answer A is incorrect because the position is inappropriate for bone marrow aspiration. Answer D is not a required preprocedure diet change. Although the client might receive a local anesthetic and/or pain medication, amnesic medications such as Versed are not usually administered, so answer C is incorrect.
A client is admitted to the emergency room with a complaint of chest pain. The physician suspects a myocardial infarction and orders heparin and nitroglycerin. Which home medication, taken just before admission, would the nurse report to the ER physician immediately?
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Solution
Answer B is correct. Nitroglycerin is contraindicated with the use of Viagra. The medications in B, C, and D have no adverse effects when administered with heparin or nitroglycerin, so they are incorrect.
The nurse is assessing the chart of a client admitted for surgery when an order is noted to administer Atropine 2mg IM as a pre-operative medication to a 40-year-old client. What initial nursing action is most appropriate?
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Solution
Answer A is correct. The usual dosage of atropine as a preoperative medication is 0.4–0.6mg. The ordered dosage is too high, so the order requires clarification. Answer B is incorrect because of the ordered dosage. Answers C and D will be required, but not before getting a correct dosage order.
A nurse would expect a client admitted with congestive heart failure to be treated with which drug?
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Solution
Answer A is correct. Clients with congestive heart failure are usually treated with a diuretic, such as Lasix and Digoxin. Answer B is a hematologic, and answer C is an anticoagulant. Skelaxin, in answer D, is a muscle relaxer. These drugs are not used to decrease fluid or improve cardiac output necessary for the treatment of congestive heart failure, so they are incorrect.
The nurse is reviewing laboratory results. Serum sodium of 156mEq/L is noted. What changes would the nurse expect the client to exhibit?
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Solution
Answer B is correct. The normal sodium is 135–145mEq/L. When hypernatremia occurs, the client can exhibit manic and hyperactivity behaviors. Other symptoms of increased sodium include restlessness, twitching, seizures, and hyperreflexia. Answers A, and C are not symptoms of high sodium levels, so they are incorrect. Answer D is associated with low sodium levels.
Which statement made by the client would alert the nurse to a possible fluid and electrolyte imbalance in an 80-year-old client being admitted to a nursing home?
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Solution
Answer B is correct. The misuse and overuse of laxatives can cause serious fluid and electrolyte imbalances in the elderly, so this is the correct choice. Answers A and D can be normal occurrences associated with the physiological changes of aging. Answer C is an incorrect response because the client states that increased fluid intake is not a new occurrence.
Which statement made by a client’s son signifies abnormal grieving by the client?
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Solution
Answer D is correct. Abnormal grieving occurs when someone acts as if nothing has happened. Answers A, B, and C are normal parts of the grieving process, so they are incorrect.
The nurse recognizes that which of the following protective equipment is most appropriate to wear when suctioning a client with a tracheostomy?
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Solution
Answer A is correct. Standard precautions require that goggles, a gown, and gloves be worn when there is a danger of contamination by splashing. Answers B and C are not adequate for the suctioning procedure. A gown is not an adequate precaution and shoe covers are not required, making answer D incorrect.
The nurse is giving instructions on the removal of ticks at a Girl Scout meeting. Which information is proper procedure for tick removal?
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Solution
Answer A is correct. The recommended procedure is to use tweezers to remove the tick, using a slow steady force, and to disinfect the area before and after doing so. Answers B, C, and D are not the correct procedure to safely remove a tick.
What would the nurse expect to see included in the treatment plan of a 14-year-old with scoliosis and an 18° curvature of the spine?
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Solution
Answer C is correct. If a client has a curvature of less than 20°, it is considered mild, with no treatment required. If after reevaluation the curve is progressing, treatment might be necessary. Answer A and B are done with curvatures greater than 20°, so they are incorrect. Answer D might be required with curvatures greater than 40°, which makes it incorrect.