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Following a coronary artery bypass, a client develops a temperature of 102°. The nurse should notify the doctor because an elevation in temperature:
- A. Increases the cardiac output
- B. Decreases the cardiac output
- C. Indicates a cardiac tamponade
- D. Increases diaphoresis and the likelihood of hypothermia
Correct Answer: B
Rationale: A fever increases metabolic demand, which can decrease cardiac output in a post-bypass patient, potentially straining the heart.
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The nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse perform FIRST?
- A. Administer aspirin 325 mg PO.
- B. Obtain a CT scan of the head.
- C. Check the client’s blood glucose level.
- D. Start an IV line.
Correct Answer: C
Rationale: Hypoglycemia can mimic stroke symptoms; checking blood glucose is the first step to rule out treatable causes. Options A, B, and D are secondary.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units at bedtime. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue in the morning.
- B. Sweating and shakiness at night.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin. Options A, C, and D are less urgent.
The physician orders naproxen sodium (Anaprox) 250 mg enteric-coated tablets PO bid for a 45-year-old man.
Which response, if made by the client, would indicate that the nurse's teaching about the medication has been effective?
- A. I can join my wife in a glass of wine with our dinner when we eat in a restaurant.'
- B. I should avoid milk and dairy products when I take this pill.'
- C. I should call my doctor if my stools turn very dark.'
- D. I don't like to take pills so I will crush the pill and add it to some applesauce.'
Correct Answer: C
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a true statement. (1) alcohol increases risk of GI bleeding (2) should be taken with food, milk, or antacid to decrease GI upset (3) correct-NSAIDS can cause GI bleeding (4) enteric-coated tablet should not be broken
A client who has overdosed on a large quantity of diazepam (Valium).
Which of the following nursing actions should take priority during the first several days of this client's inpatient treatment?
- A. Complete a full psychiatric assessment.
- B. Get in touch with the client's family to involve them in treatment.
- C. Observe and record vital signs frequently, including neurological symptoms.
- D. Determine whether this client may need long-term therapy after this hospitalization.
Correct Answer: C
Rationale: Strategy: Think Maslow. (1) psychosocial, can be done after the client has been medically stabilized (2) psychosocial, can be done after the client has been medically stabilized (3) correct-physical, because of potentially life-threatening complications of depressant overdose such as respiratory failure, pulmonary edema, and seizures, nurse's priority is observation and documentation of vital signs (4) psychosocial, can be done after the client has been medically stabilized
A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
- A. You need to take your medicine, this is how you get well.
- B. If you refuse your medicine, we'll just have to give you a shot.
- C. What is it about the medicine that you don't like?
- D. I can see that you are uncomfortable right now, I'll wait until tomorrow.
Correct Answer: C
Rationale: What is it about the medicine that you don't like? This fosters trust and open communication, encouraging the client to express concerns.