Nokea
The nurse has given the client information about the use of sublingual nitroglycerin tablets prescribed for as-needed use if chest pain occurs. Which client statement helps assure the nurse that the client understands how to self-administer the medication?
- A. I will keep the nitroglycerin in a shirt pocket close to my body.
- B. I won't take the medication until the chest pain actually begins and intensifies.
- C. If I get a headache when I first start taking the nitroglycerin, then I will take an aspirin.
- D. I will discard unused nitroglycerin tablets 3 to 6 months after the bottle is opened, and obtain a new prescription.
Correct Answer: D
Rationale: Nitroglycerin may be self-administered sublingually 5 to 10 minutes before an activity that triggers chest pain. Tablets should be discarded 3 to 6 months after opening the bottle (per expiration date), and a new bottle of pills should be obtained from the pharmacy. Nitroglycerin is unstable and is affected by heat and cold, so it should not be kept close to the body (warmth) in a shirt pocket; rather, it should be kept in a jacket pocket or a purse. Headache often occurs with early use and diminishes in time. Acetaminophen may be used to treat headache.
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The nurse is providing instructions to the mother of a child with a diagnosis of strabismus of the left eye. Which statement by the mother indicates that the mother understands the procedure for patching?
- A. I will place the patch on both eyes.
- B. I will place the patch on the left eye.
- C. I will place the patch on the right eye.
- D. I will alternate the patch from the right eye to the left eye every hour.
Correct Answer: C
Rationale: Patching may be used for the treatment of strabismus to strengthen the weak eye. With this treatment, the good eye is patched; this encourages the child to use the weaker eye. The treatment is most successful when it is performed during the preschool years. The schedule for patching is individualized and prescribed by the ophthalmologist.
A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?
- A. Weight loss of 4 ounces and dry, peeling skin
- B. Blood glucose level of 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) before the last feeding
- C. Breast-feeding for 20 minutes or more, with strong sucking
- D. High-pitched cry, drinking 10 to 15mL of formula per feeding
Correct Answer: D
Rationale: Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Blood glucose levels are acceptable at 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) during the first few days of life.
The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?
- A. Elevate the head of the bed.
- B. Provide oxygen during stressful periods.
- C. Limit the time that the infant is allowed to bottle-feed.
- D. Wake the infant for feedings to ensure adequate nutrition.
Correct Answer: D
Rationale: Awaking the child is not therapeutic in this situation. Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle-feed or breast-feed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.
The nurse is caring for a client on mechanical ventilation via an oral endotracheal tube. What are the possible causes of the high-pressure alarm sounding?
- A. A kink in the tube
- B. The client fighting the ventilator
- C. Increased secretions in the airway
- D. A cuff leak in the endotracheal tube
- E. The client biting on the endotracheal tube
- F. The ventilator tubing disconnecting from the endotracheal tube
Correct Answer: A,B,C,E
Rationale: The high-pressure alarm sounds when the peak inspiratory pressure reaches the set alarm limit. Causes include obstruction of the endotracheal tube because of the client lying on the tube or water or a kink in the tubing; the client being anxious or fighting the ventilator; an increased amount of secretions in the airways or a mucous plug; the client coughing, gagging, or biting on the oral endotracheal tube; decreased airway size related to wheezing or bronchospasm; pneumothorax; and displacement of the artificial airway and the endotracheal tube slipping into the right main stem bronchus. The low-pressure alarm sounds when there is a leak or disconnection in the ventilator circuit or a leak in the client's artificial airway cuff.
A client is prescribed glipizide once daily. What intended effect of this medication should the nurse observe for?
- A. Weight loss
- B. Resolution of infection
- C. Decreased blood glucose
- D. Decreased blood pressure
Correct Answer: C
Rationale: Glipizide is an oral hypoglycemic agent that is taken in the morning. It is not used to enhance weight loss, treat infection, or decrease blood pressure.