The physician has ordered B & O (belladonna and opium) suppositories for a client following a prostatectomy. The nurse recognizes that the medication will:
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Solution
Answer A is correct. B & O suppositories relieve pain following a prostatectomy by reducing bladder spasms. The medication does not improve urinary output, does not reduce post-operative swelling, and does not treat nausea and vomiting; therefore, answers B, C, and D are incorrect.
The nurse is caring for a client following a pneumonectomy. Which nursing intervention will help prevent an embolus?
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Solution
Answer D is correct. Ambulating the client as soon as possible prevents venous stasis and helps to prevent embolus formation. Answers A and C are measures to increase the effectiveness of respirations and help to prevent pneumonia; therefore, they are incorrect. Answer B is a treatment to break up an existing embolus; therefore, it is incorrect.
The nursing staff has planned a picnic for a small group of clients from the psychiatric unit. All of the clients are taking Thorazine (chlorpromazine). The nursing staff should take extra measures to:
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Solution
Answer A is correct. Thorazine (chlorpromazine) causes an increase in sun sensitivity; therefore, the nursing staff should take extra measures to protect the clients from sun exposure. Aged cheese and chocolate are eliminated from the diet of a client taking an MAO inhibitor; therefore, answers B and D are incorrect. Answer C is incorrect because the client taking Thorazine needs extra fluid because the anticholinergic effects of the medication cause dry mouth.
The nurse is reviewing the preoperative checklist for a client scheduled for a cholecystectomy. Which item is not required on the client’s preoperative checklist?
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Solution
Answer C is correct. The physician’s signature is not included on the preoperative checklist because it is a check sheet for the assessment and preparation of the client for surgery. The physician’s signature is required on the preoperative orders and the consent form for surgery. Answers A, B, and D are incorrect because they are required on the client’s preoperative checklist.
During the admission assessment, the nurse discovers that the client has brought her medications from home. The nurse should:
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Solution
Answer B is correct. The nurse should make a list of the medications and ask a family member to take the medications home. If no family member is available, the medication should remain locked in the medication room until the client is discharged home. Answer A is incorrect because the client might take the medication without the nurse’s knowledge, which might result in overmedication. Answer C is incorrect because over-the-counter medications and herbal supplements can interact with medications the physician might order. Answer D is incorrect because only medications supplied by the hospital pharmacy should be used while the client is hospitalized unless the physician writes an order allowing the nurse to administer medication previously purchased by the client.
A 5-month-old admitted with gastroenteritis is managed with IV fluids and is to be NPO. Which nursing intervention will provide the most comfort for the 5-month-old who is NPO?
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Solution
Answer A is correct. Providing a pacifier will provide the most comfort for the 5- month-old by providing oral gratification. Answers B, C, and D will comfort the infant, but not as much as the pacifier while he is NPO.
The nurse is cleaning up a blood spill that occurred during removal of a chest tube. The nurse should clean the blood spill using:
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Solution
Answer B is correct. According to universal precautions, blood spills should be cleaned up immediately using a weak solution of bleach (1 part bleach to 10 parts water). Answers A, C, and D are not recommended for cleaning up accidental blood spills; therefore, they are incorrect.
An elderly client with anemia has a positive Schilling test. The nurse knows that the client’s anemia is due to:
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Solution
Answer C is correct. A positive Schilling test indicates that the client has pernicious anemia, which is due to the lack of intrinsic factor. Answer A describes iron-deficiency anemia; therefore, it is incorrect. Answer B describes sickle cell anemia; therefore, it is incorrect. Answer D describes Cooley’s anemia; therefore, it is incorrect.
During a well baby visit, the mother asks the nurse when the “soft spot” on the front of her baby’s head will close. The nurse should tell the mother that the anterior fontanel normally closes by the time the baby is:
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Solution
Answer D is correct. The anterior fontanel usually closes by the time the baby is 12–18 months of age. Answers A, B and C are incorrect because the baby is too young for the anterior fontanel to be closed.
A client with acquired immunodeficiency syndrome has begun treatment with Pentam (pentamidine). The nurse recognizes that the medication will help to prevent:
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Solution
Answer B is correct. Pentamidine is used to prevent pneumocystis carinni pneumonia (PCP). Answers A, C, and D are not associated with the use of pentamidine; therefore, they are incorrect.