Nokea
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline, 25 mg/hour. Which one of the following findings by the nurse would require immediate intervention?
- A. Decreased blood pressure and respirations
- B. Flushing and headache
- C. Restlessness and palpitations
- D. Increased heart rate and blood pressure
Correct Answer: C
Rationale: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations.
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The nurse is caring for a client with a history of pancreatitis.
- A. Which dietary instruction is most appropriate for a client with chronic pancreatitis?
- B. High-fat, low-protein diet.
- C. Low-fat, high-protein diet.
- D. High-carbohydrate, low-fat diet.
- E. Low-carbohydrate, high-fat diet.
Correct Answer: B
Rationale: A low-fat, high-protein diet reduces pancreatic stimulation and supports tissue repair in chronic pancreatitis. High-fat diets exacerbate symptoms, and carbohydrate balance is less critical.
An adult who has myasthenia gravis is about to be discharged. Neostigmine is prescribed for her. What should the nurse include when teaching the client about this drug? Tell the client to take the drug:
- A. one-half hour before meals.
- B. between meals.
- C. immediately following meals.
- D. upon arising and at bedtime.
Correct Answer: A
Rationale: Taking neostigmine 30 minutes before meals maximizes muscle strength for chewing and swallowing, critical for myasthenia gravis patients, unlike other timing.
The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?
- A. Tuberculin skin testing
- B. Sputum culture
- C. White blood cell count
- D. Chest x-ray
Correct Answer: B
Rationale: Sputum culture. The sputum culture is the most accurate method for determining the presence of active TB.
It would be MOST important for the nurse to ask which of the following questions?
- A. Have your other children had chickenpox?'
- B. Does your child have a temperature?'
- C. Have you had the chickenpox?'
- D. Do you have someone to watch your child?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates there may be more than one answer that you would like to select. Remember, you can only ask one question. (1) chickenpox spread by direct contact, airborne route; not the most important question (2) fever, malaise, and anorexia occur during first 24 hours; treat with Tylenol (3) correct-need to ascertain if staff has had the disease; if not, VZIG can be given; exclude from patient care from the 10th day after first exposure through the 21st day (28th day if VZIG given) after last exposure (4) important information, but assessing staff is most important
An obstetrical client elects to have epidural anesthesia with Marcaine. After the epidural anesthesia is given, the nurse should monitor the client for signs of:
- A. Seizure activity
- B. Respiratory depression
- C. Postural hypotension
- D. Hematuria
Correct Answer: C
Rationale: Marcaine (bupivacaine) can cause vasodilation, leading to postural hypotension. Seizures, respiratory depression, and hematuria are less common.