Nokea
The client is diagnosed with essential hypertension and is receiving a calcium channel blocker. Which assessment data would warrant the nurse holding the client's medication?
- A. The client's oral temperature is 102°F.
- B. The client complains of a dry, nonproductive cough.
- C. The client's blood pressure reading is 106/76.
- D. The client complains of being dizzy when getting out of bed.
Correct Answer: D
Rationale: Dizziness on standing suggests orthostatic hypotension, a calcium channel blocker side effect, warranting holding the dose to prevent falls. Fever, cough, or BP are less critical.
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The nurse is monitoring a client receiving a thrombolytic agent, alteplase (Activase tissue plasminogen activator), for treatment of a myocardial infarction. What outcome indicates the client is receiving adequate therapy within the first hours of treatment?
- A. Absence of a dysrhythmia (or arrhythmia)
- B. Blood pressure reduction
- C. Cardiac enzymes are within normal limits
- D. Return of ST segment to baseline on ECG
Correct Answer: D
Rationale: Return of ST segment to baseline on ECG. Improved perfusion should result from this medication, along with the reduction of ST segment elevation.
The client's vital signs are T 99.2°F, AP 59, R 20, and BP 108/72. Which medication would the nurse question administering?
- A. Theo-Dur, a bronchodilator.
- B. Inderal, a beta blocker.
- C. Ampicillin, an antibiotic.
- D. Cardizem, a calcium channel blocker.
Correct Answer: B
Rationale: Inderal (propranolol) slows HR; an apical pulse of 59 warrants holding it, per guidelines, to avoid bradycardia. Other meds are unaffected by HR.
The client is receiving atropine, an anticholinergic, to minimize the side effects of routine medications. Which intervention will help the client tolerate this medication?
- A. Teach the client about orthostatic hypotension.
- B. Instruct the client to eat a low-residue diet.
- C. Encourage the client to chew sugarless gum.
- D. Discuss the importance of daily isometric exercises.
Correct Answer: C
Rationale: Atropine causes dry mouth; sugarless gum stimulates saliva, improving tolerance. Hypotension, diet, or exercises are unrelated.
The nurse administers 18 units of Humulin N, an intermediate-acting insulin, at 1630. Which priority intervention should the nurse implement?
- A. Monitor the client's hemoglobin A1c.
- B. Make sure the client eats the evening meal.
- C. Check the a.c. blood glucometer reading.
- D. Ensure the client eats a snack.
Correct Answer: B
Rationale: Humulin N peaks in 4–12 hours; evening meal prevents hypoglycemia during peak action. A1c, a.c. checks, or snacks are less immediate.
The nurse is teaching a parent how to administer oral iron supplements to a 2 year-old child. Which of the following interventions should be included in the teaching?
- A. Stop the medication if the stools become tarry green
- B. Give the medicine with orange juice and through a straw
- C. Add the medicine to a bottle of formula
- D. Administer the iron with your child's meals
Correct Answer: B
Rationale: Give the medicine with orange juice and through a straw. Absorption of iron is facilitated in an environment rich in Vitamin C. Since liquid iron preparation will stain teeth, a straw is preferred.