Extract:

Question 1 of 5

The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?

Correct Answer: A, B

Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.

Question 2 of 5

The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What should the nurse document that the client has?

A. Epidural catheter B. Hickman catheter C. Central venous catheter (CVC) D. Patient-controlled analgesia (PCA) pump

Correct Answer: A

Rationale: An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A CVC is inserted into a large vein (typically the internal or external jugular or the superior vena cava) that leads to the right atrium of the heart. A PCA pump is the device that allows the client to self-administer pain medication.

Question 3 of 5

The mother of the child diagnosed with Kawasaki disease asks the nurse about the disorder. On which description of this disorder should the nurse base the response to the mother?

A. It is an acquired cell-mediated immunodeficiency disorder. B. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. C. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown etiology. D. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.

Correct Answer: C

Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.

Question 4 of 5

A client was admitted to the surgical unit after right total knee arthroscopy performed 2 hours earlier. Which surgeon's prescription requires clarification?

A. Maintain right knee in a slightly flexed position. B. Implement patient-controlled analgesia (PCA) per my protocol. C. Place sequential compression devices on both legs while on bed rest. D. Notify physical therapy to begin isometric quadriceps exercises on the day following surgery.

Correct Answer: A

Rationale: The knee is immobilized by a compression dressing to keep the knee in extension immediately after the operation. The nurse should clarify a prescription to keep the knee slightly flexed. Pain control by use of patient-controlled analgesia, use of compression devices to reduce the risk of thromboembolism, and physical therapy to begin isometric quadriceps exercises are expected prescriptions after total knee arthroscopy surgery.

Question 5 of 5

A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?

A. Chills B. Headache C. Ringing in the ears D. Nausea and vomiting

Correct Answer: D

Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.