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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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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.
What action should the nurse take to assess the pharyngeal reflex on a child?
- A. Ask the client to swallow.
- B. Pull down on the lower eyelid.
- C. Shine a light toward the bridge of the nose.
- D. Stimulate the back of the throat with a tongue depressor.
Correct Answer: D
Rationale: The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. Asking the client to swallow assesses the swallowing reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas).
The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication?
- A. Repositions side to side every 2 hours
- B. Elevates the head of the bed 60 degrees
- C. Auscultates the lung fields every 4 hours
- D. Encourages deep breathing exercises every 2 hours
Correct Answer: B
Rationale: The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid in the abdomen. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures in the care of a client with ascites, but the priority measure is the one that relieves diaphragmatic pressure thus assisting effective respirations.
The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube. The nurse should place the client in which position to administer the feeding?
- A. Supine
- B. Semi-Fowler's
- C. Trendelenburg's
- D. Lateral recumbent
Correct Answer: B
Rationale: Clients are at high risk for aspiration during an NG tube feeding because the tube bypasses a protective mechanism, the gag reflex. The head of the bed is elevated 35 to 40 degrees (Semi-Fowler's) to prevent this complication by facilitating gastric emptying. The remaining options increase the risk of aspiration by blunting the effect of gravity on gastric emptying.