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A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
- A. Decreased anxiety
- B. Emesis of 250 mL
- C. Increased respiratory rate to 26/min
- D. Decreased urinary output
Correct Answer: A
Rationale: The correct answer is A: Decreased anxiety. Morphine is often used to relieve pain and anxiety in patients with acute heart failure. The nurse should expect a reduction in anxiety as a positive response to the medication. Emesis (choice B) is not a typical indication of morphine effectiveness. Increased respiratory rate (choice C) may indicate respiratory depression, a potential adverse effect of morphine. Decreased urinary output (choice D) could suggest decreased cardiac output, which is not necessarily a sign of morphine effectiveness in this case.
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A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an excess of carbon dioxide (CO2) in the blood, leading to a decrease in pH. This imbalance occurs when the lungs are unable to eliminate enough CO2 through respiration, causing it to accumulate in the bloodstream. This excess CO2 combines with water in the blood to form carbonic acid, leading to acidosis. Choices B, C, and D are incorrect as they do not directly relate to the accumulation of CO2 in respiratory acidosis. Loss of bicarbonate (B) would lead to metabolic acidosis, excessive vomiting (C) would cause metabolic alkalosis, and hyperventilation (D) would actually help in decreasing CO2 levels, which is not the case in respiratory acidosis.
A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer?
- A. Daily caffeine consumption
- B. A history of seasonal allergies
- C. Oral contraceptives were taken for the last 6 years
- D. Routine use of multivitamins
Correct Answer: C
Rationale: The correct answer is C. Oral contraceptives have been associated with an increased risk of breast cancer due to the hormonal changes they induce in the body. Estrogen and progesterone in oral contraceptives can promote the growth of breast cells, potentially leading to cancer. Daily caffeine consumption (A) and a history of seasonal allergies (B) are not directly linked to breast cancer development. Routine use of multivitamins (D) is generally considered beneficial for overall health and does not increase breast cancer risk.
A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
- A. NG tube
- B. Tongue blade
- C. Wrist restraints
- D. Oral airway
Correct Answer: D
Rationale: The correct answer is D: Oral airway. During a seizure, a client may experience difficulty breathing due to their airway being obstructed. Placing an oral airway helps maintain a clear airway, ensuring adequate oxygenation. NG tube (A) is not relevant to managing seizures. Tongue blade (B) can cause injury during a seizure. Wrist restraints (C) are not appropriate and can increase the risk of injury.
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?
- A. Fluticasone
- B. Metoprolol
- C. Metformin
- D. Valproic acid
Correct Answer: C
Rationale: The correct answer is C: Metformin. The nurse should withhold metformin before the procedure with IV contrast dye due to the risk of lactic acidosis. IV contrast dye can affect kidney function, leading to an increased risk of lactic acidosis when combined with metformin. Fluticasone (A), metoprolol (B), and valproic acid (D) are not contraindicated before the procedure with IV contrast dye. Fluticasone is an inhaled corticosteroid, metoprolol is a beta-blocker, and valproic acid is an anticonvulsant. These medications are not typically affected by IV contrast dye and can be safely administered.
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration?
- A. A client who has a history of asthma
- B. A client who has hypertension
- C. A client who has a history of migraines
- D. A client who has stable angina
Correct Answer: A
Rationale: The correct answer is A: A client who has a history of asthma. Propranolol is a non-selective beta-blocker that can potentially cause bronchoconstriction in clients with asthma due to its beta-2 antagonistic effects. The nurse should clarify the prescription with the provider for this client to avoid exacerbating respiratory issues. Choices B, C, and D are not contraindications for propranolol administration, as hypertension, migraines, and stable angina are conditions that can be treated with beta-blockers. It is important for the nurse to assess each client's medical history and consider potential contraindications before administering medications to ensure client safety and optimal outcomes.