Nokea
A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:
- A. Administering bronchodilators
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring temperature
Correct Answer: A
Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.
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The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
- A. Monitor the client's blood sugar.
- B. Suction the mouth and pharynx every hour.
- C. Place the client in low Trendelenburg position.
- D. Encourage the client to cough.
Correct Answer: A
Rationale: Transphenoidal hypophysectomy can disrupt pituitary function, affecting glucose regulation. Monitoring blood sugar is critical to detect hypo- or hyperglycemia. Suctioning, positioning, or coughing is not routine.
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. I understand you're depressed, but killing yourself is not a reasonable option.'
- B. We need to discuss this further, but right now let's complete these forms.'
- C. Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.'
- D. This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.'
Correct Answer: D
Rationale: To the client, suicide may be a reasonable action and the only one he can cope with at this time. This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
Which of the following findings would be abnormal in a postpartal woman?
- A. Chills shortly after delivery
- B. Pulse rate of 60 bpm in morning on first postdelivery day
- C. Urinary output of 3000 mL on the second day after delivery
- D. An oral temperature of 101°F (38.3°C) on the third day after delivery
Correct Answer: D
Rationale: Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. A temperature of 100.4°F (38°C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4°F needs further investigation to identify any infectious process.
The patient states, 'My stomach hurts about two hours after I eat.' Based upon this information, the nurse suspects the patient likely has a:
- A. Gastric ulcer
- B. Duodenal ulcer
- C. Peptic ulcer
- D. Curling's ulcer
Correct Answer: B
Rationale: Pain 2–3 hours after eating is characteristic of a duodenal ulcer, as acid irritates the ulcerated mucosa in the duodenum post-digestion. Gastric ulcer pain typically occurs sooner after meals, peptic ulcer is a general term, and Curling’s ulcer is stress-related.
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.0 mEq/L
- B. 2.2 mEq/L
- C. 0.03 mEq/L
- D. 1.5 mEq/L
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.