Nokea
A client has been taking a prescribed calcium channel blocker therapy for approximately 2 months. The home care nurse monitoring the effects of therapy should determine that drug tolerance has developed if which is noted in the client?
- A. Decrease in weight
- B. Increased joint pain
- C. Output greater than intake
- D. Gradual rise in blood pressure
Correct Answer: D
Rationale: Drug tolerance can develop in a client taking an antihypertensive such as a calcium channel blocker, which is evident by rising blood pressure levels. The primary health care provider should be notified, who may then increase the medication dosage, change medication, or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. Joint pain is not associated with this form of tolerance.
You may also like to solve these questions
During a health assessment, the client tells the nurse that she was diagnosed with endometriosis. Which explanation presented by the client demonstrates an understanding of the description of the condition?
- A. Endometriosis is known as primary dysmenorrhea.
- B. Endometriosis is what causes me the pain that occurs when I ovulate.
- C. Endometriosis is the condition that has caused me to stop menstruating.
- D. Endometriosis means that I have uterine tissue growing outside my uterus.
Correct Answer: D
Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure, function, and response to estrogen and progesterone during the menstrual cycle. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods coinciding with ovulation. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea, the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation, can result from a variety of causes.
The nurse is caring for a client diagnosed with pneumonia. When considering the client's safety, when will the nurse plan to take the client for a short walk?
- A. After the client eats lunch
- B. After the client has a brief nap
- C. After the client uses the metered-dose inhaler
- D. After assessing the client's oxygen saturation
Correct Answer: C
Rationale: The nurse should schedule activities for the client with pneumonia after the client has received respiratory treatments or medications. After the administration of bronchodilators (often administered by metered-dose inhaler), the client has the best oxygen exchange possible and would tolerate the activity best. Still, the nurse implements activity cautiously, so as not to increase the client's dyspnea. The client would become fatigued after eating; therefore, this is not a good time to ambulate the client. Although the client may be rested somewhat after a nap, the respiratory status of the client may not be at its best. Although monitoring oxygen saturation is appropriate, the intervention itself does not affect the client's respiratory function.
The nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant?
- A. Placing the infant under phototherapy
- B. Keeping the infant NPO until the second period of reactivity
- C. Encouraging the mother to breast-feed the infant every 2 to 3 hours
- D. Encouraging the mother to supplement breast-feeding with formula
Correct Answer: C
Rationale: To help prevent jaundice, the mother should feed the infant frequently in the immediate birth period because colostrum is a natural laxative and helps promote the passage of meconium. Breast-feeding should begin as soon as possible after birth while the infant is in the first period of reactivity.
A client has a prescription to receive an enema before bowel surgery. The nurse assists the client into which position to administer the enema?
- A. enema_1.PNG
- B. enema_2.PNG
- C. enema_3.PNG
- D. enema_4.PNG
Correct Answer: C
Rationale: When administering an enema, the nurse places the client in a Sims' position (option 3) exposing the rectal area and allowing the enema solution to flow by gravity in the natural direction of the colon. In the prone position (option 1), the client is lying on the stomach. In the supine position (option 2), the client is lying on the back. The dorsal recumbent position (option 4) is used for abdominal assessment because it promotes relaxation of abdominal muscles.
The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position?
- A. High Fowler's
- B. Trendelenburg's
- C. Lateral recumbent
- D. Reverse Trendelenburg's
Correct Answer: B
Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.