Nokea
A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?
- A. Heart rate and blood pressure
- B. Blood glucose levels
- C. Respiratory rate
- D. Liver function tests
Correct Answer: A
Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.
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An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?
- A. Apply bilateral eye patches while sleeping
- B. Use a whiteboard to communicate with the client
- C. Arrange food on the plate in a clockwise order
- D. Verbally identify oneself when entering the room
Correct Answer: A
Rationale: The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.
A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client's dichotomous tendency?
- A. I am glad you like me. Which nurse was acting aloof to you?
- B. Tomorrow I will talk to that nurse about how you were treated last night.
- C. What did the night nurse do that makes you think she is aloof?
- D. I am happy that you are getting better and will be able to go home.
Correct Answer: A
Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.
Which instruction is most important for the client who receives a new prescription for risedronate sodium to treat osteoporosis?
- A. Remain upright for 30 minutes after taking the medication
- B. Increase intake of foods rich in vitamin D
- C. Begin a low-impact exercise routine
- D. Take the medication with a full glass of water
Correct Answer: A
Rationale: The most important instruction for a client receiving risedronate sodium to treat osteoporosis is to remain upright for 30 minutes after taking the medication. Risedronate sodium can cause esophageal irritation, and staying upright helps prevent this side effect. While increasing vitamin D intake, starting a low-impact exercise routine, and taking the medication with a full glass of water are all beneficial for managing osteoporosis, the immediate need is to prevent esophageal irritation caused by risedronate sodium.
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?
- A. Encourage the parents to allow the child to continue attending swimming lessons with supervision
- B. Suggest that the child be encouraged to participate in a team sport to promote socialization
- C. Explain that their child is not mature enough to understand the risks associated with swimming
- D. Provide a list of alternative activities that are less likely to cause the child to experience fatigue
Correct Answer: A
Rationale: Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the most appropriate response. Swimming can be beneficial for the child, providing both exercise and enjoyment. Supervision can help manage any risks associated with swimming. Choice B is incorrect because the child's preference for swimming should be respected, and swimming can still offer socialization opportunities. Choice C is incorrect as it undermines the child's capability to understand the situation. Choice D is less appropriate as it does not address the child's interest in swimming and may limit beneficial physical activity.
A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?
- A. The heart will stop beating, and you will stop breathing.
- B. You will go to sleep and not wake up.
- C. Your body will stop functioning, and you will no longer feel pain.
- D. You will feel very tired, and your body will shut down slowly.
Correct Answer: C
Rationale: The correct answer is C because it provides a truthful yet sensitive response to the child's question. Saying that the body will stop functioning and that there will be no more pain helps the child understand what to expect without unnecessary details or causing distress. Choice A is too technical and may not be suitable for a child. Choice B might give the impression of a peaceful passing, which may not always be the case. Choice D introduces the concept of feeling tired, which might not be accurate or helpful in this context.