NR 101 EXIT EXAM | ANSWERS WITH RATIONALE

NR 101 EXIT EXAM A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h." (1) H1 receptor blocker, used as an antiemetic (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST? 1. A woman in the first trimester of pregnancy complains of heartburn. 2. A man complains of heartburn that radiates to the jaw. 3. A woman complains of hot flashes and difficulty sleeping. 4. A boy complains of knee pain after playing basketball. (1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing (2) correct—indicates chest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions?