Nokea
A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- A. Fever, sore throat, weakness
- B. Dry mouth, constipation, blurred vision
- C. Lethargy, slurred speech, thirst
- D. Fatigue, drowsiness, photosensitivity
Correct Answer: A
Rationale: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate reporting.
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The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.
The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client's diagnosis?
- A. A sweat potassium concentration less than 40 mEq/L
- B. A sweat chloride concentration greater than 60 mEq/L
- C. A sweat potassium concentration greater than 40 mEq/L
- D. A sweat chloride concentration less than 40 mEq/L
Correct Answer: B
Rationale: A sweat chloride concentration greater than 60 mEq/L is diagnostic for cystic fibrosis, indicating defective chloride transport.
Following insertion of a nasogastric (NG) tube, the nurse aspirates the gastric contents to check the pH to determine if the NG tube is correctly placed. Which of the following pH values is consistent with gastric secretions?
- A. 8
- B. 6
- C. 5
- D. 4
Correct Answer: D
Rationale: Gastric secretions typically have a pH of 1.5-3.5, so a pH of 4 (D) is consistent with correct NG tube placement in the stomach. Higher pH values (A, B, C) suggest placement in the intestines or respiratory tract.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10 bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions.
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at contraction ends indicates severe distress, an ominous sign.
The registered nurse is making assignments for the day. Which client should not be assigned to the pregnant nurse?
- A. The client receiving linear accelerator radiation therapy for lung cancer
- B. The client with a radium implant for cervical cancer
- C. The client who has just been administered soluble brachytherapy for thyroid cancer
- D. The client who returned from an intravenous pyelogram
Correct Answer: B
Rationale: A radium implant emits radiation, posing a risk to the fetus, so the pregnant nurse should not care for this client.