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A nurse is caring for a woman who delivered a term neonate at 6 a.m. At 4 p.m., the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client's output record. What should the nurse do first?
- A. Apply a warm, moist towel over the bladder.
- B. Ask the woman to sit on the toilet while the nurse runs water from the faucet.
- C. Administer Tylenol with codeine.
- D. Use an in-and-out catheter to empty the bladder.
Correct Answer: D
Rationale: A distended bladder causing pain requires immediate relief via catheterization to prevent complications like urinary retention or bladder injury.
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The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses?
- A. Imbalanced nutrition: Less than body requirements.
- B. Acute pain related to abdominal muscle spasms.
- C. Adult failure to thrive.
- D. Ineffective health maintenance.
Correct Answer: A
Rationale: Poor appetite, nausea, and vomiting indicate inadequate nutritional intake, supporting the diagnosis of imbalanced nutrition.
A client with a history of stroke is prescribed clopidogrel (Plavix). The nurse should monitor the client for which of the following adverse effects?
- A. Bleeding.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring.
The nurse calls the primary health care provider to express concerns about a chemotherapeutic medication dose prescribed by the primary health care provider being too high. The primary health care provider office informs the nurse that the primary health care provider has left town and will not be available for several days. What action should the nurse take next to assure client safety?
- A. Reschedule the client's chemotherapy until the next week.
- B. Withhold giving the medication until the primary health care provider's partner makes rounds.
- C. Telephone the answering service and confer with the on-call primary health care provider.
- D. Confer with the pharmacist, who agrees the dose is too high, and then reduces the dose accordingly.
Correct Answer: C
Rationale: If the nurse believes a primary health care provider's prescription to be in error, the nurse must clarify the dosage with the client's primary health care provider or the primary health care provider's substitute before administering the medication. Rescheduling the client's chemotherapy is incorrect. Chemotherapy must be administered on a specific schedule for maximum effect with minimum adverse effects. Additionally, only a prescriber can withhold or reschedule chemotherapy. Withholding the medication until the partner makes rounds is incorrect. Chemotherapy agents must be administered in the proper combinations or sequence in order to be effective. Checking with the pharmacist can assist the nurse in determining whether the dose prescribed is incorrect, but the nurse or pharmacist cannot alter the dose without a revised prescription from a licensed primary health care provider with prescriptive authority.
A client with atrial fibrillation is prescribed digoxin (Lanoxin). Which finding indicates a potential toxicity?
- A. Heart rate of 80 bpm.
- B. Visual disturbances.
- C. Blood pressure of 120/80 mm Hg.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Visual disturbances, such as blurred or yellow vision, are classic signs of digoxin toxicity, requiring immediate reporting.
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Severe headache.
- D. Increased urine output.
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.