Nokea
A client has begun medication therapy with betaxolol. The nurse determines that the client is experiencing the intended effect of therapy if which observation is noted?
- A. Edema present at 3+
- B. Weight loss of 5 pounds within 2 days
- C. Pulse rate increased from 58 to 74 beats/min
- D. Blood pressure decreased from 142 / 94mmHg to 128 / 82mmHg
Correct Answer: D
Rationale: Betaxolol is a beta-adrenergic blocking agent used to lower blood pressure, relieve angina, or eliminate dysrhythmias. Side/adverse effects include bradycardia and symptoms of heart failure, such as weight gain and increased edema.
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An adult client with hyperkalemia is prescribed sodium polystyrene sulfonate. Which serum potassium level is a clinical indicator of effective therapy?
- A. 4.9 mEq/L (4.9 mmol/L)
- B. 5.4 mEq/L (5.4 mmol/L)
- C. 5.8 mEq/L (5.8 mmol/L)
- D. 6.2 mEq/L (6.2 mmol/L)
Correct Answer: A
Rationale: The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Option 1 is the only option that reflects a value within this range. The remaining options identify hyperkalemic levels.
A client who had a laryngectomy for laryngeal cancer has started oral intake. The nurse determines that the first stage of dietary advancement has been tolerated when the client ingests which type of diet without aspirating or choking?
- A. Bland
- B. Full liquids
- C. Clear liquids
- D. Semisolid foods
Correct Answer: D
Rationale: Oral intake after laryngectomy is started with semisolid foods. When the client can manage this type of food, liquids may be introduced. A bland diet is not appropriate. The client may not be able to tolerate the texture of some of the solid foods that would be included in a bland diet. Thin liquids are not given until the risk of aspiration is negligible.
A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication?
- A. The client is afebrile.
- B. The client has clear breath sounds.
- C. The client reports no episodes of headache.
- D. The client has a blood pressure of 118 / 72mmHg .
Correct Answer: D
Rationale: Nadolol is a beta-adrenergic blocking agent that is used to treat hypertension. Therefore, a blood pressure within the normal range would indicate an effective response to the medication. Based on this information the remaining options are unrelated to the action of this medication.
The nurse is assessing a client with gestational hypertension who was admitted to the hospital 48 hours ago. Which current assessment data would indicate that the condition has not yet resolved?
- A. Urinary output is increased.
- B. Presence of trace urinary protein
- C. Client complaints of blurred vision
- D. Blood pressure reading at prenatal baseline
Correct Answer: C
Rationale: Client complaints of headache or blurred vision indicate a worsening of the condition and warrant immediate further evaluation. The remaining options are all signs that the gestational hypertension is being resolved.
The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
- A. The client denies a need for assistance with care.
- B. The client allows the family to assist in the care.
- C. The client assists in self-care as much as possible.
- D. The client allows the nurse to complete the care on a daily basis.
Correct Answer: C
Rationale: A successful outcome for reassuming self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to perform the care.