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A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
- A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
- B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
- C. The additive effect of multiple medications has caused the blood pressure to drop too low.
- D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
Correct Answer: C
Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.
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The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?
- A. Evaluate the oxygen saturation.
- B. Administer a bronchodilator.
- C. Assist the client to sit upright.
- D. Encourage slow, deep breathing.
Correct Answer: A
Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.
The parents of a 6-year-old recently diagnosed with asthma should be taught that symptoms of an acute episode of asthma are due to which physiological response?
- A. Inflammation of the mucous membrane and bronchospasm
- B. Increased mucus production and airway obstruction
- C. Hyperinflation of the lungs and alveolar collapse
- D. Bronchoconstriction and airway inflammation
Correct Answer: D
Rationale: The correct answer is D: Bronchoconstriction and airway inflammation. During an acute asthma episode, bronchoconstriction and airway inflammation occur, leading to difficulty breathing. Choices A, B, and C are incorrect. Inflammation of the mucous membrane and bronchospasm (Choice A) are part of the pathophysiology of asthma but do not fully explain the symptoms during an acute episode. Increased mucus production and airway obstruction (Choice B) are also seen in asthma but are not the primary cause of acute symptoms. Hyperinflation of the lungs and alveolar collapse (Choice C) are not typical features of an acute asthma episode.
A client with hyperthyroidism is admitted to the postoperative unit after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?
- A. Total calcium 5.0 mg/dL.
- B. Serum sodium 140 mEq/L.
- C. Serum potassium 4.0 mEq/L.
- D. Serum glucose 90 mg/dL.
Correct Answer: A
Rationale: The correct answer is A. A calcium level of 5.0 mg/dL is critically low and could indicate hypoparathyroidism, a possible complication after thyroidectomy. Low calcium levels can lead to tetany, seizures, and cardiac dysrhythmias, requiring immediate intervention. Choices B, C, and D fall within the normal range and do not require immediate intervention in this scenario.
The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take?
- A. Call the healthcare provider who wrote the prescription
- B. Attempt to clarify the prescriptions with the pharmacist
- C. Administer the medications as prescribed
- D. Ask another healthcare provider for clarification
Correct Answer: A
Rationale: The correct action for the charge nurse to take is to call the healthcare provider who wrote the illegible prescriptions. It is crucial to clarify illegible prescriptions directly with the provider to ensure patient safety and prevent medication errors. Option B, attempting to clarify with the pharmacist, may lead to misinterpretation and is not the recommended first step. Administering the medications as prescribed without clarity can jeopardize patient safety, making option C incorrect. Asking another healthcare provider for clarification (option D) may not be effective as the responsibility lies with the provider who wrote the prescription.
A client is admitted with a diagnosis of pneumonia and is receiving IV antibiotics. Which assessment finding indicates that the treatment is effective?
- A. Client reports less chest pain.
- B. Client's white blood cell count is decreasing.
- C. Client has a decreased respiratory rate.
- D. Client has clear breath sounds.
Correct Answer: D
Rationale: The correct answer is D. Clear breath sounds indicate that the pneumonia is resolving and the treatment is effective. Breath sounds are often muffled or crackling in pneumonia due to the presence of fluid or inflammation in the lungs. Clear breath sounds suggest that the air is moving freely through the lungs, indicating improvement. Choices A, B, and C are less specific indicators of pneumonia resolution. While less chest pain and a decreasing white blood cell count can be positive signs, they are not as direct in indicating the effectiveness of pneumonia treatment as the presence of clear breath sounds. A decreased respiratory rate could be seen in various conditions and may not solely indicate the resolution of pneumonia.