Nokea
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
- A. Pedal pulses 11 (weak)
- B. Twenty-four-hour intake 1000 mL/day for past 2 days
- C. Serum potassium 3.3
- D. Pulse rate 150 bpm
Correct Answer: B
Rationale: (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
You may also like to solve these questions
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:
- A. There are stones present in her gallbladder
- B. There are stones present in her kidneys
- C. There are stones present in her common bile duct
- D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain
Correct Answer: C
Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, adverts an adult, include:
- A. Fewer alveoli, slower respiratory rate
- B. Diaphragmatic breathing, larger volume of air
- C. Larger number of alveoli, diaphragmatic breathing
- D. Rounded shape of chest, smaller volume of air
Correct Answer: D
Rationale: Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. The adult has a larger number of alveoli than a child. The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
- A. Push during contractions
- B. Hyperventilate during contractions
- C. Walk between contractions
- D. Relax during contractions
Correct Answer: A
Rationale: The second stage of labor is marked by full cervical dilation and the urge to push with contractions.
As soon as a child has been diagnosed as 'hearing impaired,' special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?
- A. Auditory training
- B. Speech
- C. Lip reading
- D. Signing
Correct Answer: B
Rationale: With the slight and mild hard of hearing, auditory training is beneficial. Speech is the most difficult task because it is learned by visual and auditory stimulation, imitation, and reinforcement. (C, D) Lip reading and signing are aimed at establishing communicative skills, but they are learned more easily by visual stimulation.
The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.