Nokea
Following Nitroglycerin patch application
An expected outcome experienced by the client would be one of the following:
- A. Elevated blood pressure
- B. Tachycardia
- C. Tingling sensation
- D. Increased urine output
Correct Answer: B
Rationale: Nitroglycerin may cause reflex tachycardia as a compensatory response to vasodilation.
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The nurse administers prescribed pancreatin replacement therapy to Bonnie.
To effectively evaluate the effect of this treatment, should expect that this medication will result to
- A. Bulky, foul, smelly stools.
- B. Close to normal stools.
- C. Loose, frequent stools.
- D. Constipation.
Correct Answer: B
Rationale: Pancreatin aids fat digestion, resulting in near-normal stools in pancreatic insufficiency.
The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:
- A. maturation.
- B. organization.
- C. readiness to learn.
- D. self-efficacy.
Correct Answer: D
Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.
The patient with DM has flu.
Which nursing action is more appropriate?
- A. Frequent monitoring of blood glucose.
- B. Expected increase in the patient insulin requirement.
- C. Implement respiratory isolation.
- D. Monitor the patient's respiratory status frequently.
Correct Answer: A
Rationale: Flu can disrupt glucose control, making frequent monitoring critical.
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Positioning the patient with the head of the bed elevated 60°-90° (high Fowler’s position) facilitates swallowing and allows gravity to aid the passage of the nasogastric (NG) tube through the esophagus into the stomach. This position reduces the risk of aspiration and eases tube insertion. Lower elevations (30°-45°), side-lying, or flat positions do not optimize swallowing or tube advancement as effectively.
An adult is to go to surgery this morning. When the nurse goes to medicate the client, she notes that she has a ring with several shiny stones in it on her left ring finger. There are no relatives present. What is the best nursing action?
- A. Tape the ring before medicating the client.
- B. Ask the client to put the ring in the bedside drawer.
- C. Label the ring and place it in an envelope in the hospital safe.
- D. Have the client sign a waiver regarding responsibility for the ring.
Correct Answer: C
Rationale: Securing valuables in the hospital safe protects the ring during surgery, adhering to safety protocols. Taping, bedside storage, or waivers risk loss.