Nokea
A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?
- A. When I take in a deep breath, it stabs like a knife.'
- B. The pain came on after dinner. That soup seemed very spicy.'
- C. When I turn to the left, it feels like my heart is being squeezed.'
- D. The pain radiates to my jaw and left arm.'
Correct Answer: D
Rationale: Chest pain radiating to the jaw and left arm is a classic symptom of myocardial infarction, requiring immediate action to assess for a life-threatening cardiac event.
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An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?
- A. Encouraging frequent fluid intake
- B. Keeping the bed elevated and side rails raised
- C. Providing one-on-one supervision
- D. Turning the lights off in the client's room
Correct Answer: C
Rationale: One-on-one supervision (C) ensures safety for a confused, agitated client at risk for falls or harm. Fluids (A), side rails (B), and dim lights (D) are secondary or inappropriate.
Which of the following herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply.
- A. Black cohosh
- B. Garlic
- C. Ginger
- D. Ginkgo biloba
- E. Hawthorn
Correct Answer: B,C,D
Rationale: Garlic (B), ginger (C), and ginkgo biloba (D) have antiplatelet effects, increasing bleeding risk. Black cohosh (A) and hawthorn (E) do not significantly affect bleeding.
The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
- A. Administer calcium gluconate
- B. Call the provider immediately
- C. Discontinue the magnesium sulfate
- D. Perform additional assessments
Correct Answer: C
Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
- A. Review the client's weight pattern over the year
- B. Ask the mother to record her diet for the last 24 hours
- C. Encourage her to talk about her view of herself
- D. Give her several pamphlets on postpartum nutrition
Correct Answer: C
Rationale: Encourage her to talk about her view of herself. To an adolescent, body image is very important, and addressing this concern first facilitates further assessment.
A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client?
- A. A diet rich in protein and vitamin D will help with absorption.
- B. If the tablet is too large to swallow, crush and take it in applesauce or pudding.
- C. Potassium tablets should be taken on an empty stomach.
- D. Take it with plenty of water and sit upright for a period of time afterward.
Correct Answer: D
Rationale: Potassium chloride tablets should be taken with water and the client should remain upright to prevent esophageal irritation or ulceration (D). Protein and vitamin D (A) do not enhance absorption, crushing tablets (B) can cause irritation, and taking on an empty stomach (C) is unnecessary.