Nokea
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect
- B. Most antipsychotic drugs cause elevated blood pressure
- C. This provides information on the amount of sodium allowed in the diet
- D. It will indicate the need to institute antiparkinsonian drugs
Correct Answer: A
Rationale: Orthostatic hypotension is a common side effect. Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after receiving medication. They should be advised to get up slowly, especially from a supine position.
You may also like to solve these questions
A college student is hospitalized with meningococcal meningitis after being seen in the campus clinic. What is the nurse's responsibility to the campus community regarding this diagnosis?
- A. Quarantine all students and faculty remaining on the campus
- B. E-mail school administrators with the names of infected students
- C. Identify all individuals who have had close contact with the student
- D. Ensure that everyone on campus receive prophylactic antibiotics
Correct Answer: C
Rationale: C: Identifying close contacts allows targeted prophylaxis, preventing spread. A: Quarantine is excessive. B: Sharing names violates privacy. D: Prophylaxis is only for close contacts.
Which of these food choices, if selected by a client with diarrhea, would indicate the need for further teaching about dietary management?
- A. orange juice
- B. tuna
- C. eggs
- D. macaroni
Correct Answer: A
Rationale: Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.
The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?
- A. Breath sounds can be heard bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88 BPM
- D. Client is unable to speak
Correct Answer: C
Rationale: Pulse oximetry of 88 BPM. Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings.
Following morning shift report the nurse plans to assess clients who had surgery two days ago. Which client should the nurse assess first?
- A. 30-year-old who had a splenectomy and has an oral temperature of 102.2°F (39°C)
- B. 69-year-old who had a right total hip arthroplasty and has a WBC count of 12,100/mm3
- C. 55-year-old who had a lumbar discectomy and was given 30 mg oral oxycodone at 0700
- D. 40-year-old with external traction for a tibia fracture and has a platelet count of 100 K/mm3
Correct Answer: A
Rationale: A: High fever post-splenectomy suggests possible sepsis, requiring immediate assessment. B: Slightly elevated WBC is expected. C, D: Pain management and low platelets are less urgent.
A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?
- A. Sodium
- B. Potassium
- C. Phosphate
- D. Albumin
Correct Answer: B
Rationale: Potassium. If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys.