Nokea
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
- A. Hypotension
- B. Photosensitivity
- C. Excessive appetite
- D. Dryness of the mouth
Correct Answer: B
Rationale: Protection from the sun is important in clients taking phenothiazines like chlorpromazine because they burn easily and severely.
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A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in one-half normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 5-1/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
- A. Provide food and fluids at the client's request
- B. Maintain IV, increasing the rate hourly until the client voids
- C. Report to the surgeon if the client is unable to void within 8 hours of surgery
- D. Hold morphine sulfate injections for pain until the client voids, explaining to her that morphine sulfate can cause urinary retention
Correct Answer: C
Rationale: Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 2, ab 1
- B. Gravida 5, para 3, ab 1
- C. Gravida 5, para 4, ab 0
- D. Gravida 4, para 3, ab 0
Correct Answer: B
Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.
The nurse is caring for a client with a history of Crohn’s disease. Which dietary recommendation is most appropriate?
- A. High-fiber diet
- B. Low-residue diet
- C. High-fat diet
- D. Low-protein diet
Correct Answer: B
Rationale: A low-residue diet reduces bowel irritation in Crohn’s disease, minimizing symptoms like diarrhea. High-fiber diets exacerbate symptoms, and high-fat or low-protein diets are not indicated.
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
- A. Digoxin (Lanoxin)
- B. Lidocaine (Xylocaine)
- C. Quinidine gluconate or sulfate (Quinaglute, Quinidex)
- D. Nitroglycerin IV (Tridil)
Correct Answer: B
Rationale: Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities
- A. 7
- B. 10
- C. 8
- D. 9
Correct Answer: A
Rationale: Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flexion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.