Nokea
A client is receiving dopamine hydrochloride for treatment of shock. The nurse should:
- A. Administer pain medication concurrently.
- B. Monitor blood pressure continuously.
- C. Evaluate arterial blood gases at least every 2 hours.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Dopamine can cause significant changes in blood pressure due to its inotropic and vasopressor effects. Continuous blood pressure monitoring is essential to titrate the dose and prevent complications. Pain medication, arterial blood gases, and infection monitoring are not primary.
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A client is discharged after being hospitalized for thrombophlebitis. She will be driving home with her daughter, who lives 2 hours away. During the 2-hour ride, the nurse should advise the client to:
- A. Perform arm circles while riding in the car
- B. Perform ankle pumps and foot range-of-motion exercises
- C. Elevate her legs while riding in the car
- D. Take an ambulance home
Correct Answer: B
Rationale: Ankle pumps and foot range-of-motion exercises during the car ride promote venous return, preventing stasis and recurrent thrombophlebitis. Arm circles are irrelevant, elevating legs is impractical, and an ambulance is unnecessary for a discharged client.
A client post-amputation is experiencing depression. Which nursing action is most appropriate?
- A. Administer an antidepressant immediately.
- B. Encourage participation in a support group.
- C. Limit discussions about the amputation.
- D. Schedule a physical therapy session.
Correct Answer: B
Rationale: Encouraging participation in a support group fosters emotional coping and peer support.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage?
- A. Numbness.
- B. Bleeding.
- C. Dislocation.
- D. Pinkness.
Correct Answer: A
Rationale: Numbness indicates potential nerve damage, requiring urgent evaluation.
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses and treats bleeding, blood products (C) correct hypovolemia, and a Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention.