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A nurse is planning care for a client who has a new prescription for metoprolol (Lopressor). Which assessment finding should the nurse report to the healthcare provider before administering the medication?
- A. Heart rate of 50 beats per minute
- B. Blood pressure of 90/60 mm Hg
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 99°F (37.2°C)
Correct Answer: A
Rationale: A heart rate of 50 beats per minute is a concerning finding that should be reported before administering metoprolol. Metoprolol is a beta-blocker that can further lower the heart rate, so a heart rate of 50 bpm indicates potential bradycardia, which is a contraindication for administering this medication. Choices B, C, and D are within normal ranges and do not pose immediate concerns related to metoprolol administration.
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The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
- A. Tachycardia, mental status change, and low urine output
- B. Warm skin, hypertension, and constricted pupils
- C. Bradycardia, hypotension, and respiratory acidosis
- D. Mottled skin, tachypnea, and hyperactive bowel sounds
Correct Answer: A
Rationale: The correct answer is A: Tachycardia, mental status change, and low urine output are early signs of shock. Tachycardia is the body's compensatory mechanism to maintain perfusion, mental status changes can indicate decreased cerebral perfusion, and low urine output reflects poor renal perfusion. Choices B, C, and D are incorrect. Warm skin, hypertension, and constricted pupils are not typical findings in the early stages of shock. Bradycardia, hypotension, and respiratory acidosis are more indicative of late-stage shock. Mottled skin, tachypnea, and hyperactive bowel sounds can be seen in various conditions but are not specific early signs of shock.
The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, 'What do you think you're doing?' How should the nurse respond?
- A. I cannot give you this medication until you calm down.
- B. This shot will help relieve the pain in your feet.
- C. Would you prefer to learn to administer your own shot?
- D. You will feel calmer and less jittery after this shot.
Correct Answer: B
Rationale: Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication. Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses. Choice A focuses on the client's behavior rather than the therapeutic effect of the injection. Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation. Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.
A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?
- A. Explain the program's guidelines
- B. Search all personal belongings
- C. Initiate psychosocial assessment
- D. Review the healthcare provider's prescription
Correct Answer: B
Rationale: Searching personal belongings is essential to ensure the safety of the client by preventing access to items that could be used for self-harm. While explaining the program's guidelines (Choice A) and initiating a psychosocial assessment (Choice C) are important aspects of care, the immediate concern in this situation is the safety of the client. Reviewing the healthcare provider's prescription (Choice D) is important for providing appropriate treatment but is not as urgent as ensuring the client's safety.
An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct Answer: B
Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.
When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?
- A. I will use crutches to keep my weight off my knee
- B. I will stay home until a wheelchair is delivered
- C. I can use the trapeze bar and side rails on the bed to help me turn regularly
- D. I can put my full weight on my foot starting the day after surgery
Correct Answer: A
Rationale: The correct answer is A. Using crutches indicates an understanding of weight-bearing restrictions post-surgery. Choice B is incorrect because waiting for a wheelchair is not related to postoperative mobility instructions. Choice C is incorrect as turning in bed using the trapeze bar and side rails does not address weight-bearing restrictions. Choice D is incorrect because putting full weight on the foot immediately after surgery contradicts the need to keep weight off the knee.