Nokea
A client is admitted with symptoms of vertigo and syncope.
- A. Memory loss and disorientation
- B. Numbness in the face, mouth, and tongue
- C. Radial pulse differences over 10 bpm
- D. Frontal headache with associated nausea or emesis
Correct Answer: C
Rationale: Left subclavian artery obstruction can cause subclavian steal syndrome, leading to vertigo, syncope, and radial pulse differences (>10 bpm) due to blood flow reversal. Memory loss (A), numbness (B), and headache (D) are unrelated.
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The nurse is teaching a client with a history of gout about dietary modifications. The nurse should tell the client to avoid:
- A. Green leafy vegetables
- B. Organ meats
- C. Whole grains
- D. Dairy products
Correct Answer: B
Rationale: Organ meats are high in purines, which increase uric acid levels, exacerbating gout, so they should be avoided.
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat.
- B. Place a small heater near the child's bed.
- C. Turn the child at least every two hours.
- D. Allow one side to dry before changing positions.
Correct Answer: C
Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.
A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of the following prescribed medications would best relieve this problem?
- A. Acetaminophen suppository 650 mg
- B. Meperidine 50 mg IM
- C. Promethazine 25 mg IM
- D. Aminocaproic acid (Amicar) 6 g/24 hr
Correct Answer: D
Rationale: Acetaminophen (Tylenol) has analgesic and antipyretic actions approximately equivalent to those of aspirin. It produces analgesia possibly by action on the peripheral nervous system. It reduces fever by direct action on the hypothalamus heat-regulating center with consequent peripheral vasodilation. It is generally used for temporary relief of mild to moderate pain, such as a simple headache, minor joint and muscle pains, and control of fever. Meperidine is a narcotic agonist analgesic with properties similar to morphine except that it has a shorter duration of action and produces less depression of urinary retention and smooth muscle spasm. It is used for moderate to severe pain, for a preoperative medication, for support of anesthesia, and for obstetrical analgesia. In a postoperative TURP client, it would be used in conjunction with other medications for relief of moderate to severe pain, but not specifically for bladder spasms associated with TURP surgery. Promethazine hydrochloride is an antihistamine, antiemetic preparation. It exerts antiserotonin, anticholinergic, and local anesthetic actions. It is used for symptomatic relief of various allergic conditions, motion sickness, nausea, and vomiting. It is used for preoperative, postoperative, and obstetrical sedation and as an adjunct to analgesics for control of pain. This answer is correct because aminocaproic acid is prescribed specifically for hematuria. Aminocaproic acid is excreted in the urine. The nurse should be alert for possible signs of thrombosis, particularly in the extremities.
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
- A. Call the physician immediately and give dopamine IM
- B. Turn her on her left side and recheck her blood pressure in 5 minutes
- C. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids
- D. Increase the rate of IV fluids and start O2 by mask
Correct Answer: D
Rationale: Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of >30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
A client with a history of colorectal cancer is admitted with complaints of abdominal pain. The nurse should give priority to:
- A. Monitoring for obstruction
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Abdominal pain in colorectal cancer may indicate obstruction, a serious complication requiring immediate monitoring.