Nokea
A client with a history of heart failure is prescribed lisinopril (Prinivil). The nurse should monitor the client for which of the following adverse effects?
- A. Hyperkalemia.
- B. Hypotension.
- C. Weight loss.
- D. Tachycardia.
Correct Answer: A, B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia and hypotension.
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A primigravid client at 26 weeks' gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following?
- A. Increased peristaltic action during pregnancy.
- B. Displacement of the stomach by the diaphragm.
- C. Decreased secretion of hydrochloric acid.
- D. Backflow of stomach contents into the esophagus.
Correct Answer: D
Rationale: Heartburn is caused when stomach contents enter the distal end of the esophagus, producing a burning sensation. To avoid heartburn during pregnancy, the client should avoid spicy foods; eat smaller, more frequent meals; and avoid lying down after eating. Peristalsis usually decreases during the latter half of pregnancy. Displacement of the stomach by the uterus, not the diaphragm, may contribute to heartburn. Increased, not decreased, secretion of hydrochloric acid can exacerbate heartburn.
A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract?
- A. Compression.
- B. Lavage.
- C. Decompression.
- D. Gavage.
Correct Answer: C
Rationale: An NG tube is used for decompression to remove air and fluid from the gastrointestinal tract post-surgery.
A client receives morphine for postoperative pain. Which of the following assessments should the nurse include in the client's plan of care?
- A. Take apical heart rate after each dose of morphine.
- B. Assess urinary output every 8 hours.
- C. Assess mental status every shift.
- D. Check for pedal edema every 4 hours.
Correct Answer: C
Rationale: Morphine can cause sedation and altered mental status, requiring regular assessment to monitor for adverse effects.
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
- A. Symmetrical chest movement.
- B. Tracheal deviation to the affected side.
- C. Dull percussion note on the affected side.
- D. Absent breath sounds on the affected side.
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
- A. Notify the primary health care provider.
- B. Remove the blanket from the client's bed.
- C. Document the finding and recheck the temperature in 4 hours.
- D. Administer acetaminophen and recheck the temperature in 4 hours.
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.