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A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
- A. Serum potassium is 3.5 mEq/L.
- B. Blood pressure is 88/46.
- C. ST elevation is present on the electrocardiogram.
- D. Heart rate is 61.
Correct Answer: B
Rationale: Nitroglycerin causes vasodilation, which can lower blood pressure. A blood pressure of 88/46 indicates hypotension, a significant concern as it may compromise perfusion, making it the priority assessment.
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A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial?
- A. Psychotherapy.
- B. Regular exercise.
- C. Day care for the granddaughter.
- D. Weekly visits by another person with MS.
Correct Answer: B
Rationale: Regular exercise is most beneficial, as it maintains mobility, strength, and overall health in MS. Psychotherapy, daycare, or peer visits may help but are less directly impactful.
A client post-hemodialysis reports dizziness. The nurse should:
- A. Check blood pressure.
- B. Administer fluids.
- C. Encourage eating.
- D. Increase dialysis time.
Correct Answer: A
Rationale: Dizziness may indicate hypotension, a common post-dialysis issue.
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. To align injured bones.
- B. To provide long-term pull.
- C. To apply 25 lb of traction.
- D. To pull weight with a boot.
Correct Answer: C
Rationale: The amount of traction (e.g., 25 lb) is specific to the injury and not a general purpose, indicating a misunderstanding.
A client has been diagnosed with vasospastic disorder (Raynaud's phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client will obtain relief. The client's history reveals that he lives in Vermont and works outside in the logging industry. He smokes two packs of cigarettes a day. Which of the following components are an important part of the discharge plan for this client? Select all that apply.
- A. Stopping smoking
- B. Wearing a face covering and gloves in the winter
- C. Placing fingertips in cool water to rewarm them
- D. Finding employment that can be done in a warm environment
- E. Reporting signs of orthostatic hypotension
Correct Answer: A,B,D,E
Rationale: Rationales: A) Stopping smoking reduces vasoconstriction triggered by nicotine, critical in Raynaud's. B) Face covering and gloves protect against cold, a trigger for vasospasm. D) Working in a warm environment minimizes cold exposure. E) Reserpine may cause orthostatic hypotension, requiring monitoring. C) Cool water worsens vasospasm; warm water is recommended.