Nokea
The nurse administering a dose of scopolamine to a preoperative client should monitor the client for which common side effect of the medication?
- A. Dry mouth
- B. Diaphoresis
- C. Excessive urination
- D. Pupillary constriction
Correct Answer: A
Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication.
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The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
- A. Fears of abandonment and attention seeking
- B. Enjoyment of bothering the staff
- C. Boredom suggesting the need for something to do
- D. Lack of desire for involvement in milieu activities
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.
Which of the following baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
- A. Potassium level.
- B. Lee-White clotting time.
- C. Hemoglobin level, hematocrit, and platelet count.
- D. Blood glucose level.
Correct Answer: C
Rationale: These tests assess bleeding risk, critical before administering thrombolytics like alteplase, which can cause hemorrhage.
Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?
- A. Avoid shaving with straight-edge razors.
- B. Clean the skin daily with antibacterial soap.
- C. Apply moisturizing lotion before and after each treatment.
- D. Keep the radiated area covered with a sterile gauze dressing.
Correct Answer: A
Rationale: Avoiding straight-edge razors prevents skin irritation in the radiated area, which is sensitive.
A client with a history of heart failure is admitted with dyspnea. The nurse should place the client in which of the following positions?
- A. Fowler's position.
- B. Supine position.
- C. Trendelenburg position.
- D. Left lateral position.
Correct Answer: A
Rationale: Fowler's position (semi-upright) reduces preload and eases breathing in heart failure.
The nurse monitors the client for a hypoglycemic reaction, knowing that NPH insulin peaks in approximately how many hours following administration?
- A. 1 hour
- B. 2 to 3 hours
- C. 4 to 12 hours
- D. 16 to 24 hours
Correct Answer: C
Rationale: NPH is an intermediate-acting insulin with a peak time in 4 to 12 hours. The remaining options describe periods of time that are either too short or too long.