Nokea
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
- A. IV fluid rate
- B. Pedal pulses
- C. Nasal cannula flow rate
- D. Capillary refill
Correct Answer: B
Rationale: A significant drop in blood pressure post-femoral-popliteal bypass graft suggests possible hypoperfusion or graft occlusion. Assessing pedal pulses first is critical to ensure the graft is patent and blood flow is restored to the lower extremity. Compromised pulses could indicate graft failure, requiring immediate intervention. IV fluid rate, nasal cannula flow rate, and capillary refill are secondary considerations after confirming vascular patency.
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The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to:
- A. Take a laxative.
- B. Follow a clear liquid diet.
- C. Administer an enema.
- D. Take an antiemetic.
Correct Answer: A
Rationale: A laxative is typically recommended after an upper GI series to help eliminate the barium used in the procedure and prevent constipation.
A client with end-stage cancer is receiving morphine for pain. The family is concerned about addiction. The nurse should explain that:
- A. Addiction is not a concern in terminal illness.
- B. Morphine will be tapered to prevent addiction.
- C. Addiction is common but manageable.
- D. Morphine should be avoided to prevent addiction.
Correct Answer: A
Rationale: In terminal illness, addiction is not a concern, as the priority is pain control to ensure comfort, and this explanation reassures the family.
Which of the following statements about nasoenteric tubes is correct?
- A. The tube cannot be attached to suction.
- B. The tube contains a soft rubber bag filled with mercury.
- C. The tube is taped securely to the client's cheek after insertion.
- D. The tube can have its placement determined only by auscultation.
Correct Answer: C
Rationale: Nasoenteric tubes are taped securely to the client's cheek to prevent dislodgement. They can be attached to suction, do not typically use mercury today, and placement is confirmed by methods like X-ray, not just auscultation. CN: Physiological adaptation; CL: Apply
A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect?
- A. The ventricular rate is increasing.
- B. The absent pulse is now palpable.
- C. The number of premature ventricular contractions is decreasing.
- D. The fine ventricular fibrillation changes to coarse ventricular fibrillation.
Correct Answer: C
Rationale: Amiodarone treats ventricular arrhythmias. A decrease in PVCs indicates the drug is stabilizing the cardiac rhythm, its desired effect.
The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following?
- A. Hypokalemia.
- B. Hyperkalemia.
- C. Hypocalcemia.
- D. Disulfiram (Antabuse)-like symptoms.
Correct Answer: D
Rationale: Sulfonylureas combined with alcohol can cause disulfiram-like symptoms, such as flushing, nausea, and palpitations.