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The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Continue to monitor the vital signs
- B. Contact the physician
- C. Ask the client how he feels
- D. Ask the LPN to continue the post-op care
Correct Answer: B
Rationale: Hypotension (BP 90/50), tachycardia (pulse 132), and tachypnea (respirations 30) indicate potential shock or hemorrhage post-surgery, requiring immediate physician notification. Monitoring is secondary, and delegating or asking about feelings delays intervention.
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The client is admitted with a diagnosis of postpartum depression. Which vital sign change is most likely to be observed?
- A. Normal vital signs
- B. Fever
- C. Tachycardia
- D. Hypotension
Correct Answer: A
Rationale: Postpartum depression is a psychological condition and typically does not cause vital sign changes. Fever tachycardia or hypotension suggest physical conditions like infection or hemorrhage.
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.5 mg
- C. 0.05 mg
- D. 20 mg
Correct Answer: A
Rationale: 1 mg = 0.1 mL, then 0.5 mL X = 5 mg.
A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could:
- A. Counteract the effects of antibiotics
- B. Elevate the blood pressure
- C. Mask symptoms of increasing intracranial pressure
- D. Stimulate the central nervous system
Correct Answer: C
Rationale: Analgesic medication does not counteract the effects of antibiotics. Analgesic medication may lower blood pressure elevated due to anxiety. Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. Analgesics do not stimulate the CNS.
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
- A. Explain what will take place and what she will see, feel, and hear.
- B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
- C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
- D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
Correct Answer: A
Rationale: Providing a detailed explanation of the procedure helps reduce anxiety by preparing the child for what to expect, addressing her previous experience.
Which meal selection is most appropriate for a patient with iron deficiency anemia?
- A. Roast turkey,gelatin,green beans
- B. Chicken salad, sandwich,coleslaw,French fries
- C. Egg salad on wheat bread,carrot sticks ,spinach and kale salad
- D. Pork chop,mashed potatoes,green peas
Correct Answer: C
Rationale: Spinach and kale are rich in iron ,which is essential for correcting iron deficiency anemia. The other meal options do not contain significant iron-rich foods making them less appropriate for this condition.