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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At 11 AM a patient returned to the nursing unit from the postanesthesia care unit (PACU) following a hemorrhoidectomy. At noon the patient complains of pain. The physician has ordered meperidine (Demerol) 50 mg IV q 3-4 hrs. The chart indicates that the patient was given Demerol 50 mg IV at 9:15 AM.
The nurse should
- A. ask the physician if the dosage of Demerol can be increased.
- B. give the patient Demerol 25 mg IV now.
- C. have the patient wait until 1 PM before giving the Demerol.
- D. give the patient Demerol 50 mg IV now.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to call the physician (2) can't change amount of medication ordered by physician (3) medication is ordered every 3 to 4 hours, should not wait if patient needs medication after 3 hours (4) correct-give patient the medication as ordered
A client with clotting disorder has an order to continue Lovenox (Enoxaparin) injections after discharge. In assessing the client's readiness for teaching, the most important factor for the nurse to assess is the client's:
- A. Prior knowledge of anticoagulants and their role in controlling his disease
- B. Willingness to learn about injection techniques and site selection
- C. Adaptation to the need for daily injections to control his symptoms
- D. Overall intelligence and developmental level
Correct Answer: B
Rationale: Willingness to learn is critical for effective teaching about self-administering injections. Knowledge, adaptation, and intelligence are secondary.
The nurse has just returned to the desk and has four phone messages to return.
Which of the following messages should the nurse return FIRST?
- A. A man with swelling of his left wrist following a fall from a ladder two hours ago.
- B. A woman who had a cholecystectomy one week ago and now complains of redness and tenderness at the incision site.
- C. A mother of a child reports that her son's lips are swollen following a fire ant bite.
- D. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101.2°F (38.4°C).
Correct Answer: C
Rationale: Strategy: Remember the ABCs. (1) wrist needs to be x-rayed, not a priority (2) indicates infection, treated with antibiotic (3) correct-potential anaphylactic reaction, administer epinephrine, corticosteroids; treat for shock (4) indicates infection, treat with an antibiotic
The nurse is caring for a woman who is admitted following a beating by her husband. The woman says, 'It wasn't really his fault. Dinner was late.' The husband arrives to visit his wife with a large bouquet of flowers and a box of chocolates. The woman later says to the nurse, 'He feels so bad about what he did and says it will never happen again.' What concept should guide the nurse when replying to the client?
- A. Men who abuse their wives and then repent usually do not do it again.
- B. The woman is quite perceptive and should be safe when she is discharged.
- C. Abuse is often followed by repentance and then again by abuse.
- D. Spousal abuse is usually a result of misbehavior on the part of the abused.
Correct Answer: C
Rationale: The cycle of abuse often includes remorse followed by repeated abuse, guiding the nurse to educate about patterns, not assume safety or blame the victim.
The nurse is caring for a client with a history of meningitis.
- A. Which precaution is most appropriate for a client with bacterial meningitis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: B
Rationale: Droplet precautions are required for bacterial meningitis (e.g., Neisseria meningitidis) to prevent transmission via respiratory secretions. Standard precautions are insufficient, and contact or airborne precautions are incorrect.