Nokea
A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
- A. Slow, deep respirations
- B. Stridor
- C. Bradycardia
- D. Air hunger
Correct Answer: D
Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (Choice A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (Choice B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (Choice C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.
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During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:
- A. Increase fluids that are high in protein
- B. Restrict fluids
- C. Force fluids and reassess blood pressure
- D. Limit fluids to non-caffeine beverages
Correct Answer: D
Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
- A. Monitor for fever every 4 hours.
- B. Require visitors to wear respiratory masks and protective clothing.
- C. Consider transfusion of packed red blood cells.
- D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct Answer: D
Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.
What intervention should the nurse implement while a client is having a grand mal seizure?
- A. Open the jaw and place a bite block between the teeth
- B. Try to place the client on his side
- C. Restrain the client to prevent injury
- D. Place pillows around the client
Correct Answer: B
Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:
- A. Verify correct placement of the tube
- B. Check that the feeding solution matches the dietary order
- C. Aspirate gastric contents to determine the amount of the last feeding remaining in the stomach
- D. Ensure that the feeding solution is at room temperature
Correct Answer: A
Rationale: The most crucial action for the nurse when preparing to administer enteral feeding via a nasogastric tube is to verify the correct placement of the tube. Proper placement of the tube is vital to prevent complications such as aspiration into the lungs. The definitive methods to confirm the position of the nasogastric tube include visualization through an x-ray or aspirating stomach contents and checking their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm placement in the stomach.
Choice B, checking that the feeding solution matches the dietary order, is important for ensuring the correct nutrition is provided but is not as critical as verifying tube placement to prevent potential harm.
Choice C, aspirating gastric contents to determine the amount of the last feeding remaining in the stomach, is a common nursing practice but is not the most crucial action when compared to ensuring correct tube placement.
Choice D, ensuring that the feeding solution is at room temperature, is relevant for patient comfort and preventing thermal injury but is not as essential as confirming correct tube placement to prevent serious complications.
A patient has a history of photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select one that doesn't apply
- A. Ciprofloxacin (Cipro)
- B. Sulfonamide
- C. Norfloxacin (Noroxin)
- D. Nitro-Dur patch
Correct Answer: D
Rationale: Nitro-Dur patch is not associated with photosensitive reactions. It is used to prevent chest pain or angina, and common side effects include headache, lightheadedness, nausea, and flushing. Choices A, B, and C are known to cause photosensitive reactions. Ciprofloxacin (Cipro), Sulfonamides, and Norfloxacin (Noroxin) are drugs that are commonly associated with photosensitivity reactions. Patients taking these medications should be advised to avoid direct sunlight and use sun protection to prevent skin reactions.