Nokea
A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?
- A. A headache is an indication of an allergy to the medication.
- B. A headache is an expected adverse effect of the medication.
- C. A headache is likely due to the anxiety about the chest pain.
- D. A headache indicates tolerance to the medication.
Correct Answer: B
Rationale: Headaches are a common side effect of nitroglycerin due to its vasodilating effects on cerebral arteries.
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A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL
A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?
- A. Liver enzymes
- B. Serum albumin
- C. Throat culture
- D. Arterial blood gases
Correct Answer: C
Rationale: Throat culture can identify streptococcal infection preceding rheumatic fever/endocarditis.
The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).
- A. Severe fluid and electrolyte imbalance
- B. Upper abdominal distention
- C. Metabolic acidosis
- D. Projectile vomiting with a fecal odor
- E. Diarrhea or ribbon-like stools
Correct Answer: A,B,D
Rationale: These reflect SBO pathophysiology: proximal distention, fluid loss/vomiting, and metabolic derangements.
A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply).
- A. The client states that pain occurs 30 minutes to 60 minutes after a meal.
- B. The client states that pain often occurs at night.
- C. The client reports a sensation of bloating.
- D. The client reports pain relieved by eating.
- E. The client experiences pain upon palpation of the epigastric region.
Correct Answer: A,B,C,D,E
Rationale: All options are common findings in gastric ulcer patients due to gastric acid secretion patterns and mucosal irritation.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Heart murmur
- B. Dependent edema
- C. Chest pain
- D. Crackles in the lungs
Correct Answer: B
Rationale: Dependent edema occurs in right-sided HF due to systemic venous congestion.