Nokea
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
- A. Nightingale agitation
- B. Extrapyramidal side effects
- C. Vomiting
- D. Anticholinergic side effects
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
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After a lobectomy for lung cancer, the nurse instructs the client to perform deep-breathing exercises to:
- A. Decrease blood flow to the lungs for rest and increased surface alveoli ventilation.
- B. Elevate the diaphragm to enlarge the thorax so that the lung surface area available for gas exchange is increased.
- C. Control the rate of air flow to the remaining lobe to decrease the risk of hyperinflation.
- D. Expand the alveoli and increase lung surface available for ventilation.
Correct Answer: D
Rationale: Deep-breathing exercises expand alveoli, increasing lung surface area for ventilation post-lobectomy.
The nurse administering a dose of scopolamine to a preoperative client should monitor the client for which common side effect of the medication?
- A. Dry mouth
- B. Diaphoresis
- C. Excessive urination
- D. Pupillary constriction
Correct Answer: A
Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication.
A client is receiving a continuous I.V. infusion of heparin. The nurse should monitor the client for which of the following adverse effects?
- A. Hypotension.
- B. Bleeding.
- C. Hypoglycemia.
- D. Tachycardia.
Correct Answer: B
Rationale: Heparin is an anticoagulant, and its primary adverse effect is bleeding, which the nurse should monitor closely.
A client returning from the postanesthesia care unit after transurethral resection of the prostate (TURP) has bladder irrigation running via a 3-way Foley catheter. The nurse should notify the primary health care provider if which color of urine is noted in the urinary drainage bag?
- A. Pale pink
- B. Bright red
- C. Dark pink
- D. Tea-colored
Correct Answer: B
Rationale: Bright red bleeding should be reported because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP but may be noted in the client with renal failure or other renal disorders.
Your client has superior vena cava syndrome. The client's wife asks you what this is. How should you respond to the client's wife? You should explain that superior vena cava syndrome is:
- A. The compression of the renal medulla.
- B. Syncope and dizziness of unknown origin.
- C. Pressure on the vena cava which is a major vein in the body.
- D. Pressure on the vena cava which is the largest artery in the body.
Correct Answer: C
Rationale: Superior vena cava syndrome is caused by compression of the superior vena cava, a major vein, leading to symptoms like swelling and shortness of breath.