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Questions 158

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Question 1 of 5

A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:

Correct Answer: D

Rationale: Before giving any emetic, the substance ingested must be known. At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. Vomiting should never be induced in an unconscious client because of the risk of aspiration.

Question 2 of 5

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Correct Answer: D

Rationale: Muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to olanzapine. Immediate transfer to a medical unit for urgent treatment is critical.

Question 3 of 5

A client with a history of trigeminal neuralgia is admitted with complaints of facial pain. The nurse should give priority to:

Correct Answer: A

Rationale: Trigeminal neuralgia causes severe facial pain, so administering analgesics is the priority to relieve discomfort.

Question 4 of 5

Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?

Correct Answer: A

Rationale: The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. 'Feeling better' indicates the drug is working and medication therapy must be continued. Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. Antacids decrease the effectiveness of digoxin.

Question 5 of 5

The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?

Correct Answer: B

Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (
A) is secondary, an ACE bandage (
C) may contaminate the wound, and prone positioning (
D) is inappropriate.

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