Nokea
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.
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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 atrial fibrillation is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring heart rate
- B. Administering pain medication
- C. Monitoring respiratory rate
- D. Administering diuretics
Correct Answer: A
Rationale: Fatigue in atrial fibrillation may indicate reduced cardiac output, so monitoring heart rate is the priority.
A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: C
Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.
Which person is at greatest risk for developing Lyme disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent outdoor exposure in areas where ticks, which transmit the disease, are prevalent.
The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:
- A. There is no test to measure abnormal hemoglobin in newborns.
- B. Infants do not have insensible fluid loss before a year of age.
- C. Infants rarely have infections that would cause them to have a sickling crises.
- D. The presence of fetal hemoglobin protects the infant.
Correct Answer: D
Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.