GCC 676 - 700

The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:

• The machine will administer only the amount that you need to control your pain without your taking any action.
• The machine has a locking device that prevents overdosing to occur.
• The machine will administer one large dose every 4 hours to relieve your pain.
• The machine is set to deliver medication only if you need it.
• -

Answer explanation

Option 1: The machine will administer only the amount that you need to control your pain without your taking any action.

Option 2: The machine has a locking device that prevents overdosing to occur.

Option 3: The machine will administer one large dose every 4 hours to relieve your pain.

Option 4: The machine is set to deliver medication only if you need it.

Option 5: -

Correct Option: Option 2 – The machine has a locking device that prevents overdosing to occur.

Explanation: The client is concerned about overdosing himself. The machine will deliver a set amount as ordered and allow the client to self-administer a small amount of medication. PCA pumps usually are set to lock out the amount of medication that the client can give himself at 5- to 15-minute intervals. Answer A does not address the client's concerns, answer C is incorrect, and answer D does not address the client's concerns.

A client has an order to remove the nasogastric tube. Which is the correct nursing action to remove the tube?

• Apply sterile gloves and untape the tube from the client's face
• Pull the tube out 2 inches, pause for 2 minutes, and repeat until the entire tube is removed
• Instill 30ml of normal saline before removing the tube
• Pull the tube out steadily and smoothly while keeping it pinched
• -

Answer explanation

Option 1: Apply sterile gloves and untape the tube from the client's face

Option 2: Pull the tube out 2 inches, pause for 2 minutes, and repeat until the entire tube is removed

Option 3: Instill 30ml of normal saline before removing the tube

Option 4: Pull the tube out steadily and smoothly while keeping it pinched

Option 5: -

Correct Option: Option 4 – Pull the tube out steadily and smoothly while keeping it pinched

Explanation: The nurse should also ask the client to hold his breath to prevent aspiration, which is the correct procedure for discontinuing an NG tube. Clean gloves should be used for this procedure, making answer A incorrect. The tube should be removed continuously without pause, so answer B is incorrect. An amount of 30ml of air—not normal saline—can be inserted before removal, so answer C is incorrect.

The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:

• 30 minutes before meals
• With each meal
• In a single dose at bedtime
• 60 minutes after meals
• -

Answer explanation

Option 1: 30 minutes before meals

Option 2: With each meal

Option 3: In a single dose at bedtime

Option 4: 60 minutes after meals

Option 5: -

Correct Option: Option 2 – With each meal

Explanation: Zantac (rantidine) is a histamine blocker. This drug should be given with meals, for optimal effect. It should not be given before meals, so answer A is incorrect. Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime, so answer C is incorrect. These drugs should not be given after meals, so answer D is incorrect.

Studies show that collaboration between the members of a multidisciplinary health care team improves quality of client care, decreases length of stay in health care facilities, and decreases the cost of health care to the client. Which members of the multidisciplinary team are responsible for collaboration in client care?

• The primary care physician and the case manager.
• The primary nurse and the case manager.
• All members of the multidisciplinary health care team.
• The primary care physician, all consulting physicians, and the case manager.
• -

Answer explanation

Option 1: The primary care physician and the case manager.

Option 2: The primary nurse and the case manager.

Option 3: All members of the multidisciplinary health care team.

Option 4: The primary care physician, all consulting physicians, and the case manager.

Option 5: -

Correct Option: Option 3 – All members of the multidisciplinary health care team.

Explanation: All members of the multidisciplinary health care team are responsible for a collaborative care approach to client care. Multidisciplinary care has significantly improved client outcomes and decreased client length of stay in health care facilities.

A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?

• Keep the bed flat, with a small pillow beneath the cast
• Provide crayons and a coloring book for play activity
• Increase her intake of high-calorie foods for healing
• Tuck a disposable diaper beneath the cast at the perineal opening
• -

Answer explanation

Option 1: Keep the bed flat, with a small pillow beneath the cast

Option 2: Provide crayons and a coloring book for play activity

Option 3: Increase her intake of high-calorie foods for healing

Option 4: Tuck a disposable diaper beneath the cast at the perineal opening

Option 5: -

Correct Option: Option 4 – Tuck a disposable diaper beneath the cast at the perineal opening

Explanation: Tucking a disposable diaper at the perineal opening will help prevent soiling of the cast by urine and stool. Answer A is incorrect because the head of the bed should be elevated. Answer B is incorrect because the child can place the crayons beneath the cast, causing pressure areas to develop. Answer C is incorrect because the child does not need high-calorie foods that would cause weight gain while she is immobilized by the cast.

A nurse is caring for a client who complains of fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. The nurse immediately puts the client in isolation. The nurse suspects that the client is suffering from which condition?

• Bronchitis
• Pneumonia
• Pneumothorax
• Tuberculosis
• -

Answer explanation

Option 1: Bronchitis

Option 2: Pneumonia

Option 3: Pneumothorax

Option 4: Tuberculosis

Option 5: -

Correct Option: Option 4 – Tuberculosis

Explanation: The nurse suspects that the client is suffering from tuberculosis. Early pulmonary tuberculosis is asymptomatic. When the bacterial load increases, nonspecific constitutional symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease burden advances, cough, sputum production, and localized symptoms such as hemoptysis may appear. This client has the classic symptoms of tuberculosis and should be placed in respiratory isolation. Bronchitis, pneumonia, and pneumothorax do not classically present with the symptoms listed and are not on respiratory isolation.

A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?

• Peanut butter cookies
• Grilled cheese sandwich
• Cottage cheese and fruit
• Fresh peach
• -

Answer explanation

Option 1: Peanut butter cookies

Option 2: Grilled cheese sandwich

Option 3: Cottage cheese and fruit

Option 4: Fresh peach

Option 5: -

Correct Option: Option 4 – Fresh peach

Explanation: The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium.

A client is admitted with Parkinson's disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be most important to report?

• Dryness of the mouth
• Spasmodic eye winking
• Dark urine
• Dizziness
• -

Answer explanation

Option 1: Dryness of the mouth

Option 2: Spasmodic eye winking

Option 3: Dark urine

Option 4: Dizziness

Option 5: -

Correct Option: Option 2 – Spasmodic eye winking

Explanation: Spasmodic eye winking could indicate a toxicity or overdose of the drug and should be reported to the physician. Other signs of toxicity include an involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are side effects but do not indicate toxicity of the drug.

Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:

• The infant should not be circumcised.
• Surgical correction will be done by 6 months of age.
• Surgical correction is delayed until 6 years of age.
• The infant should be circumcised to facilitate voiding.
• -

Answer explanation

Option 1: The infant should not be circumcised.

Option 2: Surgical correction will be done by 6 months of age.

Option 3: Surgical correction is delayed until 6 years of age.

Option 4: The infant should be circumcised to facilitate voiding.

Option 5: -

Correct Option: Option 1 – The infant should not be circumcised.

Explanation: The infant with hypospadias should not be circumcised because the foreskin is used in reconstruction. Answer B and C are incorrect because reconstruction is done between 16 and 18 months of age, before toilet training. Answer D is incorrect because the infant with hypospadias should not be circumcised.

The nurse is applying a Transderm Nitro (nitroglycerin) patch to a client with angina. When applying the patch, the nurse should:

• Shave the area before applying a new patch
• Remove the old patch and clean the skin with alcohol
• Cover the patch with plastic wrap and tape it in place
• Avoid cutting the patch because it will alter the dose
• -

Answer explanation

Option 1: Shave the area before applying a new patch

Option 2: Remove the old patch and clean the skin with alcohol

Option 3: Cover the patch with plastic wrap and tape it in place

Option 4: Avoid cutting the patch because it will alter the dose

Option 5: -

Correct Option: Option 4 – Avoid cutting the patch because it will alter the dose

Explanation: Transderm Nitro is a reservoir patch that releases the medication via a semipermeable membrane. Cutting the patch allows too much of the drug to be released. Answer A is incorrect because the area should not be shaved because it can cause skin irritation. Answer B is incorrect because the skin is cleaned with soap and water. Answer C is incorrect because the patch is not covered with plastic wrap.