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A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- A. Induce sedation.
- B. Suppress respiratory effort.
- C. Decrease chest wall compliance.
- D. Decrease respiratory secretions.
Correct Answer: B
Rationale: The correct answer is B: Suppress respiratory effort. Pancuronium is a neuromuscular blocking agent that paralyzes skeletal muscles, including the muscles involved in breathing. In ARDS, the client may have difficulty breathing due to lung damage, so pancuronium can be used to facilitate mechanical ventilation by preventing respiratory muscle movement. This allows the ventilator to control the client's breathing without interference. The other choices are incorrect because pancuronium does not induce sedation (A), affect chest wall compliance (C), or decrease respiratory secretions (D). It solely works to suppress respiratory effort by blocking neuromuscular transmission.
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A nurse is assessing a client who is receiving metoprolol. Which of the following indicates a therapeutic effect?
- A. Decreased blood pressure.
- B. Decreased dysrhythmias.
- C. Increased urine output.
- D. Decreased pulse.
Correct Answer: A
Rationale: The correct answer is A: Decreased blood pressure. Metoprolol is a beta-blocker that works by reducing heart rate and decreasing the workload on the heart, leading to a decrease in blood pressure. This is a therapeutic effect as it helps manage conditions like hypertension and angina.
Incorrect choices:
B: Decreased dysrhythmias - While metoprolol can help reduce dysrhythmias, the primary therapeutic effect is on blood pressure.
C: Increased urine output - Metoprolol does not directly affect urine output.
D: Decreased pulse - Decreasing pulse is a common side effect of metoprolol, but the therapeutic effect is primarily on blood pressure.
A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I’ll be sure to eat more foods with vitamin K.
- B. I’ll take aspirin for my headaches.
- C. I’ll use my electric razor for shaving.
- D. It’s okay to have a couple of glasses of wine with dinner each evening.
Correct Answer: C
Rationale: The correct answer is C: "I’ll use my electric razor for shaving." This statement indicates an understanding of the teaching because warfarin is a blood thinner, increasing the risk of bleeding. Using an electric razor reduces the risk of nicks and cuts, which could lead to excessive bleeding.
Incorrect choices:
A: "I’ll be sure to eat more foods with vitamin K." - Eating more vitamin K-rich foods can interfere with the effectiveness of warfarin.
B: "I’ll take aspirin for my headaches." - Aspirin is a blood thinner and should not be taken along with warfarin.
D: "It’s okay to have a couple of glasses of wine with dinner each evening." - Alcohol can interact with warfarin and increase the risk of bleeding.
Choosing option C demonstrates the client's understanding of the importance of minimizing the risk of bleeding while on warfarin therapy.
A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?
- A. Take naproxen for generalized discomfort
- B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
- C. Take diuretics early in the morning and before bedtime
- D. Exercise at least three times per week
Correct Answer: B
Rationale: The correct answer is B: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. This is crucial in heart failure management as sudden weight gain can indicate fluid retention, worsening heart failure, and the need for medication adjustment. Option A is incorrect as naproxen can worsen heart failure symptoms. Option C is incorrect as diuretics should be taken in the morning to prevent nighttime urination. Option D is incorrect as the frequency and intensity of exercise should be tailored based on the individual's condition.
A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?
- A. This stage is when testing occurs to identify boundaries of interpersonal behaviors.
- B. Consensus evolves in this stage.
- C. This stage involves constructive efforts on the part of the group members.
- D. Resistance is evident as subgroups form in this stage.
Correct Answer: B
Rationale: The correct answer is B: Consensus evolves in this stage. During the norming stage of group development, members begin to resolve conflicts and establish norms and values. Consensus-building is crucial in this stage to ensure everyone is on the same page and working towards common goals. This process helps the group to develop cohesion and unity.
Choice A is incorrect because testing occurs in the forming stage, not norming. Choice C is incorrect because constructive efforts typically occur in the performing stage, not norming. Choice D is incorrect because resistance and subgroup formation usually happen in the storming stage, not norming.