Nokea
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
- A. Clean the sutured laceration twice a day with povidone-iodine (Betadine)
- B. Remove his scalp sutures after 5 days
- C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
- D. Take meperidine 50 mg po q4-6h prn for headache
Correct Answer: C
Rationale: Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.
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A client with a history of a pituitary tumor is receiving Bromocriptine (Parlodel). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Weight gain
- D. Hair loss
Correct Answer: A
Rationale: Bromocriptine, a dopamine agonist, can cause hypotension due to vasodilation. Hyperglycemia, weight gain, and hair loss are not primary side effects.
Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
- A. Phenothiazines
- B. Anticholinergics
- C. Anti-Parkinsonian drugs
- D. Tricyclic agents
Correct Answer: B
Rationale: This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. This answer is incorrect. Anti-Parkinsonian drugs would increase the symptoms. This answer is incorrect. Tricyclic agents are used for symptoms of depression.
The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
- A. Tachycardia
- B. Hypotension
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.
A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
- A. A blood pressure reading of 130/70 with a 5-lb weight loss
- B. No side effects from antihypertensive medication and an accurate pill count
- C. No evidence of increased left ventricular hypertrophy on chest x-ray
- D. Serum blood levels of the antihypertensive medication within therapeutic range
Correct Answer: A
Rationale: A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Palpate these pulses again in 15 minutes.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Document the finding that the pulses are not palpable.
- D. Call the physician and notify the physician of this finding.
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.