Nokea
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
- A. Measure urine output hourly to assess for rental perfusion
- B. Request a prescription for pain medication
- C. Use an automated BP machine to monitor for hypotension
- D. Provide a quiet environment with low lighting
Correct Answer: C
Rationale: Monitoring blood pressure is crucial after administering an antihypertensive to ensure the client does not become hypotensive.
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A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?
- A. Hard pellets of stool
- B. Clay-colored stool
- C. Stool with fatty streaks
- D. Blood in the stool
Correct Answer: D
Rationale: Blood in the stool is a common finding during an acute exacerbation of ulcerative colitis, which is an inflammatory condition of the colon.
Which high level labs should the nurse explain can prevent cardiovascular disease?
- A. Cholesterol
- B. Triglycerides
- C. Low-density lipoproteins (LDLs)
- D. High-density lipoproteins (HDLs)
Correct Answer: D
Rationale: HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs are not protective against cardiovascular disease.
A 4-month-old infant with a ventricular septal defect (VSD) has dropped from the 20th percentile to the 5th for weight. What will the nurse practitioner recommend?
- A. Adding solid foods to the infant's diet to increase caloric intake
- B. Fortifying breast milk to increase the number of calories per ounce
- C. Stopping breastfeeding and giving 30 kcal/ounce formula
- D. Supplementing breastfeeding with 24 kcal/ounce formula
Correct Answer: B
Rationale: Infants with heart defects who have congestive heart failure (CHF) may need modification of formula or breast milk to increase calories. Fortifying breast milk is the first and best option.
A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority?
- A. Ineffective airway clearance related to edema
- B. Disturbed body image related to physical appearance
- C. Impaired urinary elimination related to fluid loss
- D. Risk for infection related to epidermal disruption
Correct Answer: A
Rationale: Airway clearance is the top priority in burn patients, especially with facial burns, as swelling can obstruct the airway.
Two days following abdominal surgery a client begins to report cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first?
- A. Encourage the client to ambulate
- B. Offer ice chips or warm liquids
- C. Auscultate the client's abdomen
- D. Assess the client's temperature
Correct Answer: C
Rationale: Auscultating the abdomen will help determine if there are any signs of bowel obstruction or ileus, which can cause the distension.