Nokea
Before administering Theo-Dur (theophylline), the nurse should check the patient's:
- A. Urinary output
- B. Blood pressure
- C. Pulse
- D. Temperature
Correct Answer: C
Rationale: Theophylline, a bronchodilator, can cause tachycardia. Checking the pulse before administration ensures the patient is not at risk for adverse cardiac effects. Urinary output, blood pressure, and temperature are less directly affected.
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The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?
- A. A 50-year-old with a fractured fibula
- B. A 20-year-old female with a wrist fracture
- C. A 21-year-old male with a fractured femur
- D. An 8-year-old with a fractured arm
Correct Answer: C
Rationale: Fat embolus is most common in long bone fractures, especially the femur, and in young adults. A 21-year-old with a femur fracture (C) is at highest risk. Fibula (A), wrist (B), and arm (D) fractures have lower risk.
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being 'on the move,' sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?
- A. Short, polite responses to interview questions
- B. Introspection related to his present situation
- C. Exaggerated self-importance
- D. Feelings of helplessness and hopelessness
Correct Answer: C
Rationale: During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. Grandiosity and an inflated sense of self-worth are characteristic of this disorder. Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:
- A. Provide respite care for the mother
- B. Facilitate optimal development
- C. Provide a demanding and challenging educational program
- D. Prepare child to enter mainstream education
Correct Answer: B
Rationale: The primary goal for a child with Down syndrome is to facilitate optimal growth and development through tailored interventions.
The nurse assesses a postoperative mastectomy client and notes the breath sounds are diminished in both posterior bases. The nurse's action should be to:
- A. Encourage coughing and deep breathing each hour
- B. Obtain arterial blood gases
- C. Increase O2 from 2-3 L/min
- D. Remove the postoperative dressing to check for bleeding
Correct Answer: A
Rationale: Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. Arterial blood gases are not indicated because there is no other information indicating impending danger. Increasing O2 rate is not indicated without additional information. Removing the dressing is not indicated without additional information.
The client is admitted with a diagnosis of abruptio placenta. Which vital sign change is most likely to be observed?
- A. Tachycardia
- B. Hypotension
- C. Fetal bradycardia
- D. All of the above
Correct Answer: D
Rationale: Abruptio placenta causes maternal tachycardia and hypotension (from bleeding) and fetal bradycardia (from hypoxia). All vital sign changes are likely in this condition.