Nokea
A nurse is administering metoprolol (Lopressor) to a patient with hypertension. Which of the following assessments is most important before administering this medication?
- A. Blood pressure
- B. Respiratory rate
- C. Temperature
- D. Oxygen saturation
Correct Answer: A
Rationale: Metoprolol, a beta-blocker, lowers blood pressure and heart rate, so assessing blood pressure prevents hypotension or bradycardia. Respiratory rate, temperature, and oxygen saturation are less critical.
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An adult is scheduled for a cardioversion next week. What should the nurse plan to include when teaching the client about the procedure?
- A. The client should be NPO for eight hours before the procedure.
- B. The client will be awake during the procedure.
- C. The procedure will probably need to be repeated every month for at least six months.
- D. The procedure is usually done for life-threatening dysrhythmias such as ventricular fibrillation.
Correct Answer: A
Rationale: Cardioversion requires sedation, so the client must be NPO for 8 hours to prevent aspiration. The client is sedated, not awake, it's not typically repeated monthly, and it's used for atrial arrhythmias, not ventricular fibrillation.
Marie is a 38-year-old primigravida who is admitted with a diagnosis of pregnancy induced hypertension (PIH).
Priority nursing care on the patient with PIH include:
- A. Urinary protein, 2 grams/24hous.
- B. HR 110 bpm.
- C. Urine output 335 ml/24 hours.
- D. Patellar reflex positive.
Correct Answer: C
Rationale: Low urine output (335 ml/24 hours) indicates possible renal involvement in PIH, a priority for monitoring and reporting to prevent further complications.
A nurse is preparing to administer an intramuscular injection. Which of the following sites is most appropriate for an adult patient?
- A. Deltoid
- B. Vastus lateralis
- C. Dorsogluteal
- D. Ventrogluteal sites
Correct Answer: D
Rationale: The ventrogluteal site is safest for IM injections in adults, minimizing nerve or vessel damage. Deltoid and vastus lateralis are alternatives but less preferred, and dorsogluteal is avoided due to sciatic nerve risk.
The nurse is caring for a preschooler who needs stitches resulting from an injury received during play in the yard. What would be the most appropriate way to prepare the child for the treatment he will receive?
- A. Tell the child the nurse and the doctor will 'make things all better.'
- B. Use dolls and explain through play and simulation what will be done.
- C. Explain to the child slowly and precisely the steps that will be taken in his treatment.
- D. Tell the child that he will have minimal scarring and that any marks will diminish over time.
Correct Answer: B
Rationale: Play-based explanation with dolls engages a preschooler's developmental level, effectively preparing them for stitches.
A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse. Which finding of this disease would the nurse not expect to see at this time?
- A. Positive sweat test
- B. Bulky greasy stools
- C. Moist, productive cough
- D. Meconium ileus
Correct Answer: C
Rationale: Moist, productive cough. Option C is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.