Nokea
Immediately after the client receives an injection of bupivacaine (Marcaine), he becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate at this time?
- A. Ask the client to talk more about what he is feeling
- B. Reassure the client that it is normal to feel restless before a procedure
- C. Assess the client's vital signs
- D. Administer epinephrine
Correct Answer: C
Rationale: Restlessness, nervousness, and a feeling of impending doom after bupivacaine injection may indicate systemic toxicity or an allergic reaction, requiring immediate vital sign assessment to guide further action. Talking, reassurance, or administering epinephrine without assessment is premature.
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Which of the following suggestions should the nurse give to an adolescent football player with Osgood-Schlatter disease of the left knee?
- A. Apply ice on the knee after playing.
- B. Use crutches until healing has occurred.
- C. Stop playing until healing has occurred.
- D. Make an appointment with a physical therapist.
Correct Answer: A
Rationale: Applying ice after activity reduces inflammation and pain in Osgood-Schlatter disease.
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). The nurse should teach the client to avoid which of the following foods?
- A. Green leafy vegetables.
- B. Citrus fruits.
- C. Whole grains.
- D. Lean meats.
Correct Answer: A
Rationale: Green leafy vegetables are high in vitamin K, which can reduce warfarin's anticoagulant effect.
The nurse is assessing a client with a suspected pulmonary embolism. Which of the following symptoms is most likely to be present?
- A. Bradycardia.
- B. Sudden chest pain.
- C. Hypotension.
- D. Fever.
Correct Answer: B
Rationale: Sudden chest pain is a common symptom of pulmonary embolism due to impaired blood flow to the lungs.
A client with a suspected stroke is admitted to the emergency department. What is the nurse's priority action?
- A. Administer aspirin as ordered.
- B. Assess neurological status.
- C. Prepare for a CT scan.
- D. Monitor blood pressure.
Correct Answer: B
Rationale: Assessing neurological status is the priority to establish a baseline and detect changes in a suspected stroke, guiding urgent interventions.
A 30-week-gestation client admitted in preterm labor is prescribed betamethasone. What should the nurse tell the client is the purpose for this medication?
- A. Promote fetal lung maturity.
- B. Delay delivery for at least 48 hours.
- C. Stop the premature uterine contractions.
- D. Prevent premature closure of the ductus arteriosus.
Correct Answer: A
Rationale: Betamethasone, a corticosteroid, is administered to increase the surfactant level and increase fetal lung maturity, reducing the incidence of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks' gestation. If adequate amounts of surfactant are not present in the lungs, respiratory distress and death are possible consequences. Delivery needs to be delayed for at least 48 hours after the administration of betamethasone in order to allow time for the lungs to mature. The remaining options are incorrect.