Nokea
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Hold the child's discharge for 1 hour.
- B. Notify the physician immediately.
- C. Discharge the child as the physician ordered.
- D. Administer an antiemetic as necessary.
Correct Answer: B
Rationale: Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should be notified immediately so that a serum theophylline level can be ordered.
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A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:
- A. The fetus has not descended into the birth canal.
- B. The fetus is in a transverse lie.
- C. The fetus is level with the ischial spines.
- D. The fetus is at increased risk for precipitate delivery.
Correct Answer: C
Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.
The nurse is teaching a client with a history of chronic sinusitis about self-care. The nurse should tell the client to:
- A. Use a humidifier
- B. Avoid hydration
- C. Use decongestants excessively
- D. Sleep with the head lowered
Correct Answer: A
Rationale: A humidifier keeps nasal passages moist, reducing irritation and promoting drainage in chronic sinusitis.
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?
- A. High protein and high calorie
- B. High calorie and high carbohydrate
- C. Low-fat 2-g sodium diet
- D. High protein and high fat
Correct Answer: B
Rationale: High carbohydrates provide high-caloric content to prevent tissue catabolism.
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:
- A. Constipation
- B. Urinary frequency
- C. Breast tenderness
- D. Abdominal pain
Correct Answer: D
Rationale: Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption, requiring immediate medical attention.
The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. Apple
- D. Milkshake
Correct Answer: C
Rationale: An apple is a healthy, easy-to-eat snack that provides nutrition without excessive sodium (chips), caffeine (cola), or high calories (milkshake), suitable for a manic client needing stability.