Nokea
A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?
- A. Check the visual difficulties
- B. Note the most recent hemoglobin level
- C. Assess for hand and joint pain
- D. Observe rhythm on telemetry monitor
Correct Answer: D
Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.
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A child with leukemia is admitted for chemotherapy, and the nursing diagnosis, 'altered nutrition, less than body requirements related to anorexia, nausea, vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Allow the child to eat foods desired and tolerated
- B. Restrict foods brought from fast food restaurants
- C. Recommend eating the same foods as siblings eat at home
- D. Encourage a variety of large portions of food at every meal
Correct Answer: A
Rationale: Allowing the child to choose foods can help improve intake and reduce nausea. Choice A is the correct intervention as it empowers the child to select foods they desire and can tolerate, which is crucial in ensuring adequate nutrition intake. Choice B is incorrect because restricting certain foods can further limit the child's options and may not address the underlying issues. Choice C is incorrect as it doesn't consider the specific needs and preferences of the child with altered nutrition. Choice D is incorrect as encouraging large portions of food at every meal may be overwhelming for a child experiencing anorexia, nausea, and vomiting.
A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?
- A. Assess client's knowledge of an allergic response
- B. Record 'no known drug allergies' on the preoperative checklist
- C. Flag 'no known drug allergies' on the front of the chart
- D. Assess client's allergies to non-drug substances
Correct Answer: B
Rationale: The most important action to take in this situation is to record 'no known drug allergies' on the preoperative checklist. This ensures that all healthcare staff involved in the surgery are aware of the client's stated lack of drug allergies, helping to prevent any potential adverse reactions. Assessing the client's knowledge of an allergic response (Choice A) may be valuable but is not the most crucial action at this point. Flagging 'no known drug allergies' on the front of the chart (Choice C) is less practical and visible compared to documenting it on the preoperative checklist. Assessing the client's allergies to non-drug substances (Choice D) is not the priority in this scenario where the focus is on medications due to the upcoming surgery.
A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include in the discharge teaching?
- A. Engage in physical exercise before eating to help decrease cholesterol levels.
- B. Avoid walking briskly in cold weather to prevent a decrease in cardiac output.
- C. Keep nitroglycerin in a light-colored plastic bottle and readily available.
- D. Avoid all isometric exercises, but walk regularly.
Correct Answer: C
Rationale: The correct answer is to keep nitroglycerin in a light-colored container and readily available. Nitroglycerin should be protected from light to maintain its effectiveness. Option A is incorrect because physical exercise immediately before eating can trigger angina. Option B is incorrect as cold weather can exacerbate angina symptoms. Option D is incorrect as isometric exercises can increase the workload on the heart, which is not recommended for individuals with angina.
A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
- A. Increased urinary clearance of the multiple medications has led to diuresis and lowered the blood pressure.
- B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.
- C. The additive effect of multiple medications has caused the blood pressure to drop too low.
- D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
Correct Answer: C
Rationale: The correct answer is C. When a client experiences syncope due to a significant drop in blood pressure after receiving multiple antihypertensive medications, the additive effect of these medications can cause the blood pressure to drop excessively. This additive effect can lead to hypotension, which is why the nurse decided to hold the client's scheduled antihypertensive medication. Choices A, B, and D provide incorrect rationales. Choice A mentions diuresis, which is not directly related to the drop in blood pressure due to additive medication effects. Choice B refers to an antagonistic interaction reducing effectiveness, which is not applicable in this scenario. Choice D talks about a synergistic effect leading to drug toxicity, which is not the cause of the sudden drop in blood pressure observed in the client.
Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?
- A. Nurse will check client q1h for the presence of chest pain
- B. Client has a nervous, tense personality and is likely to overreact
- C. Client states he will notify the nurse if chest pain returns
- D. Client understands how to use the call button and the telephone
Correct Answer: C
Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.