Nokea
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
- A. Request a prescription for an antihypertensive medication
- B. Ask the client if she is having pain
- C. Request a prescription for an anti-anxiety medication
- D. Return in 30 minutes to recheck the client's BP
Correct Answer: B
Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice D) is not as proactive as addressing the potential pain issue immediately.
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A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effect?
- A. Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds.
- B. Some meds may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver.
- C. Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity.
- D. Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. The 1st-pass effect refers to the metabolism of a drug in the liver before it reaches systemic circulation.
2. Medications administered orally undergo first-pass metabolism in the liver, leading to potential inactivation.
3. Administering such meds through nonenteral routes (e.g., intravenous) bypasses the liver, avoiding inactivation.
4. Choice A discusses receptor activity, not related to the first-pass effect.
5. Choice C refers to drug elimination rate, not specific to the first-pass effect.
6. Choice D discusses safety margin and monitoring, not directly related to drug metabolism.
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
- A. Macaroni & cheese
- B. Fresh fruit & whole wheat toast
- C. Rice pudding & ripe bananas
- D. Roast chicken & white rice
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (A) and rice pudding & ripe bananas (C) are low in fiber and may worsen constipation. Roast chicken & white rice (D) lack sufficient fiber to alleviate constipation.
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
- A. Place the client in semi-Fowler's position
- B. Have the client rest an arm across the abdomen
- C. Observe one full respiratory cycle before counting the rate
- D. Count the rate for one minute if it is regular
- E. Count & report any sighs the client demonstrates
Correct Answer: A, B, C
Rationale: The correct guidelines for measuring a client's respiratory rate are to place the client in semi-Fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle before counting the rate. Placing the client in semi-Fowler's position helps with optimal lung expansion and breathing efficiency. Having the client rest an arm across the abdomen can help the nurse visualize the rise and fall of the chest more clearly. Observing one full respiratory cycle before counting the rate ensures accuracy in counting. These guidelines are essential for obtaining an accurate respiratory rate. Choices D and E are incorrect as counting for one minute is unnecessary if the rate is regular, and counting and reporting sighs is not part of the respiratory rate measurement process.
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all.
- A. Repeat the details of the prescription back to the provider
- B. Have another nurse listen to the telephone prescription
- C. Obtain the prescriber's signature on the prescription within 24hrs
- D. Decline the verbal prescription because it is not an emergency situation
- E. Tell the charge nurse that the provider has prescribed morphine by telephone
Correct Answer: A, B, C
Rationale: The correct choices are A, B, and C. A nurse should repeat the prescription back to the provider to ensure accurate communication and prevent errors. Having another nurse listen to the prescription can provide an additional check for accuracy and clarity. Obtaining the prescriber's signature on the prescription within 24 hours is necessary for documentation and legal purposes. Choice D should be ruled out as it is not appropriate to decline a valid prescription for pain medication in a timely manner. Choice E does not address the immediate need to confirm and document the prescription accurately.