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A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
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The nurse is reinforcing discharge teaching with the parent of a 6-year-old client who had a tonsillectomy 4 hours ago. The nurse should reinforce that it would be a priority to notify the health care provider if the client experiences
- A. Ear pain
- B. Foul-smelling breath
- C. Frequent swallowing
- D. Low-grade fever
Correct Answer: C
Rationale: Frequent swallowing (C) may indicate bleeding, a serious post-tonsillectomy complication requiring immediate reporting. Ear pain (A), bad breath (B), and low-grade fever (D) are common and less urgent.
An adult client is showing signs of developing hypovolemic shock. Which finding is most likely to be present?
- A. Elevated systolic and lowered diastolic blood pressure
- B. Decreased heart rate
- C. Decreased urine output
- D. Decreased respiratory rate
Correct Answer: C
Rationale: Hypovolemic shock reduces circulating volume, decreasing renal perfusion and causing oliguria (decreased urine output). Blood pressure typically narrows, heart rate increases, and respiratory rate rises.
The nurse is reviewing new medication prescriptions for a client with an acute exacerbation of asthma. Which of the following prescriptions should the nurse clarify?
- A. Albuterol 2.5 mg via nebulizer every 4 hours
- B. Potassium chloride 20 mEq (20 mmol) IV every 24 hours
- C. Enoxaparin 40 mg subcutaneously every 24 hours
- D. Methylprednisolone sodium succinate 20 mg IV every 6 hours
Correct Answer: B
Rationale: Potassium chloride (B) is not indicated for asthma exacerbation unless hypokalemia is documented, requiring clarification. Albuterol (A), methylprednisolone (D) treat asthma, and enoxaparin (C) may prevent thrombosis in immobile patients.
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with over dosage?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct Answer: B
Rationale: Lidocaine Hydrochloride can cause fatigue and confusion if an over dosage occurs.
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
- A. Low tar cigarettes are less harmful during pregnancy
- B. There is a relationship between smoking and low birth weight
- C. The placenta serves as a barrier to nicotine
- D. Moderate smoking is effective in weight control
Correct Answer: B
Rationale: There is a relationship between smoking and low birth weight. Smoking reduces placental blood flow, contributing to fetal hypoxia and low birth weight.