Nokea
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline, 25 mg/hour. Which one of the following findings by the nurse would require immediate intervention?
- A. Decreased blood pressure and respirations
- B. Flushing and headache
- C. Restlessness and palpitations
- D. Increased heart rate and blood pressure
Correct Answer: C
Rationale: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations.
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The nurse is caring for a client with a history of type 2 diabetes who is receiving exenatide (Byetta) 10 mcg SC bid. Which of the following symptoms should the nurse report immediately?
- A. Mild nausea
- B. Upper abdominal pain
- C. Occasional thirst
- D. Mild fatigue
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious exenatide side effect. Options A, C, and D are less urgent: nausea is common, thirst is expected, and fatigue is nonspecific.
A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
- A. I understand that a glass of wine with dinner is healthy.
- B. Beer is not really hard alcohol, so I guess I can drink some.
- C. If I drink, my baby may be harmed before I know I am pregnant.
- D. Drinking with meals reduces the effects of alcohol.
Correct Answer: C
Rationale: If I drink, my baby may be harmed before I know I am pregnant. This reflects awareness of alcohol's early fetal risks.
The nurse is caring for a client who is postoperative day 1 after a mitral valve replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Heart rate of 90 bpm.
- C. Chest tube drainage of 100 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-valve replacement due to risk of endocarditis, requiring immediate evaluation. Options B, C, and D are expected or normal: heart rate 90 bpm, drainage 100 mL/hour, and blood pressure 130/80 mmHg are stable.
Which of the following indicates the MOST appropriate diet choices for breakfast?
- A. Applesauce, cream of wheat, toast.
- B. Scrambled eggs and toast, one slice of bacon.
- C. One glass of grapefruit juice.
- D. Bagel with two ounces of cream cheese and a banana.
Correct Answer: A
Rationale: Strategy: Determine the topic of the question. (1) correct-breakfast with some substance won't leave her feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the client feeling very hungry before lunch (4) high fat content
The nurse is caring for a 79-year-old client. Which observation is not normal and should be reported for follow-up?
- A. The client has several brown spots on her cheek and neck.
- B. The client says, 'I move slower than I used to.'
- C. The client is short of breath when walking down the hall.
- D. The client says, 'I have trouble telling the colors of my socks.'
Correct Answer: C
Rationale: Shortness of breath with exertion may indicate cardiovascular or respiratory issues, requiring follow-up. Brown spots, slower movement, and color vision changes are normal aging signs.