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The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client?
- A. Excessive salivation is a side effect.
- B. There will be some pain at the injection site.
- C. There should be relief from nausea within 5 minutes.
- D. The client may experience increased agitation for about 2 hours.
Correct Answer: B
Rationale: Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective.
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When a client experiences frequent runs of ventricular tachycardia, the primary health care provider prescribes flecainide. Because of the effects of the medication, which nursing intervention is specific to this client's safety?
- A. Monitor the client's urinary output.
- B. Assess the client for neurological problems.
- C. Ensure that the bed rails remain in the up position.
- D. Monitor the client's vital signs and electrocardiogram (ECG) frequently.
Correct Answer: D
Rationale: Flecainide is an antidysrhythmic medication that slows conduction and decreases excitability, conduction velocity, and automaticity. However, the nurse must monitor for the development of a new or worsening dysrhythmia. Options 1, 2, and 3 are components of standard care but are not specific to this medication.
A client in labor has a diagnosis of sickle cell anemia. Which action will the nurse take to assist in preventing the client from experiencing a sickling crisis during labor?
- A. Being reassuring
- B. Administering oxygen
- C. Preventing bearing down
- D. Maintaining strict asepsis
Correct Answer: B
Rationale: During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Intravenous (IV) fluid therapy will also reduce the risk of a sickle cell crisis.
The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip. What is the initial action to be taken by the nurse?
- A. Notify the primary health care provider.
- B. Initiate cardiopulmonary resuscitation (CPR).
- C. Continue to monitor the client and the heart rate patterns.
- D. Administer oxygen with a face mask at 8 to 10 L per minute.
Correct Answer: B
Rationale: The monitor is showing ventricular fibrillation, a life-threatening dysrhythmia that requires CPR and defibrillation to maintain life. Although the primary health care provider must be notified, CPR is the initial action. Oxygen is necessary, but again the initiation of CPR is the priority because it will provide more than just oxygen to the client. Monitoring the client is necessary, but not as an initial action; emergency resuscitative treatment must be provided to the client immediately.
The nurse is preparing to assess the respirations of several newborns in the nursery. The nurse performs the procedure and determines that the respiratory rate is normal if which finding is noted?
- A. A respiratory rate of 30 breaths per minute in a crying newborn
- B. A respiratory rate of 46 breaths per minute in an awake newborn
- C. A respiratory rate of 60 breaths per minute in a sleeping newborn
- D. A respiratory rate of 76 breaths per minute in a newly delivered newborn
Correct Answer: B
Rationale: Normal respiratory rate varies from 30 to 50 breaths per minute when the infant is not crying. Respirations should be counted for 1 full minute to ensure an accurate measurement because the newborn infant may be a periodic breather. Observing and palpating respirations while the infant is quiet promotes accurate assessment.
A client scheduled for pneumonectomy tells the nurse that a friend had lung surgery that required chest tubes. The client asks how long to expect chest tubes to be in place. Which statement by the nurse appropriately educates the client about the presence of a chest tube postpneumonectomy?
- A. They are generally removed after 36 to 48 hours.
- B. Not every lung surgery requires chest tubes to be used.
- C. They usually remain in place for a full week after surgery.
- D. Your type of surgery rarely requires chest tubes to be inserted after surgery.
Correct Answer: D
Rationale: Pneumonectomy involves removal of the entire lung, usually caused by extensive disease such as bronchogenic carcinoma, unilateral tuberculosis, or lung abscess. Chest tubes are not inserted because the cavity is left to fill with serosanguineous fluid, which later solidifies.