Nokea
The nurse asks a patient about current medications. Which one of the patient's medications is most likely to cause abdominal pain?
- A. Norco (hydrocodone/APAP)
- B. Erythrocin (erythromycin)
- C. Zyrtec (cetirizine)
- D. Aldactone (spironolactone)
Correct Answer: B
Rationale: Erythromycin commonly causes gastrointestinal side effects, including abdominal pain, due to its motility-stimulating effects. Norco may cause constipation, Zyrtec is less likely to affect the GI tract, and Aldactone’s side effects are primarily electrolyte-related.
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To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:
- A. Finger
- B. Earlobe
- C. Extremity with noninvasive BP cuff
- D. Nose
Correct Answer: C
Rationale: A pulse oximeter should not be placed on an extremity with a blood pressure cuff, as cuff inflation can interrupt blood flow and cause inaccurate readings. Fingers, earlobes, and the nose are acceptable sites when circulation is adequate.
A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?
- A. Notify the physician.
- B. Elevate the head of the bed.
- C. Place the client in the left lateral decubitus position.
- D. Stop the TPN and hang D5 1/2 NS.
Correct Answer: C
Rationale: Air embolism is suspected. Placing the client in the left lateral decubitus position traps air in the right atrium, preventing pulmonary embolism. Notifying the physician (A), elevating the bed (B), or changing fluids (D) is secondary.
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
- A. Notify physician of nonreassuring FHR pattern.
- B. Turn the client to her left side.
- C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
- D. Evaluate to see if the monitor strip is reassuring.
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
Which of the following electrolyte imbalances is likely to result in a shortened QT interval?
- A. Hypercalcemia
- B. Hyponatremia
- C. Hypomagnesemia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: Hypercalcemia shortens the QT interval on an ECG by accelerating cardiac repolarization. Hyponatremia hypomagnesemia and hyperphosphatemia are more likely to prolong the QT interval or have other ECG effects.
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
- A. Fruit juices
- B. Diluted carbonated drinks
- C. Soy-based, lactose-free formula
- D. Regular formulas mixed with electrolyte solutions
Correct Answer: C
Rationale: Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. Regular formulas contain lactose, which can increase diarrhea.