Nokea
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
- A. The client's BP is 110/70
- B. The client's potassium level is 3.4 mEq/L
- C. The client has a barky cough
- D. The client's apical pulse is 56
Correct Answer: D
Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering a beta blocker as the blood pressure is within normal range. Choice B is not directly related to the administration of a beta blocker. Choice C may indicate a potential adverse effect of another medication, but it does not specifically warrant questioning the administration of the beta blocker.
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Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client's medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?
- A. Explain to the client that it is too early to have an injection for pain
- B. Call the practitioner, report the client's symptoms, and obtain further orders
- C. Reposition the client for greater comfort and turn on the television as a distraction
- D. Prepare the injection and administer it to the client early because of the severe pain
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to call the practitioner, report the client's symptoms, and obtain further orders. The client's symptoms, including severe abdominal pain, pallor, perspiration, thready rapid pulse, and feeling faint, are indicative of potential complications like internal bleeding, which require immediate medical evaluation. Explaining to the client that it is too early for pain medication or repositioning the client for comfort are not appropriate actions given the severity of the symptoms. Administering the injection early without consulting the practitioner can be dangerous and may worsen the client's condition.
A patient with hypothyroidism should be advised to consume more of which nutrient?
- A. Calcium
- B. Iodine
- C. Vitamin C
- D. Iron
Correct Answer: B
Rationale: The correct answer is B: Iodine. Iodine is crucial for the production of thyroid hormones. A deficiency in iodine can lead to hypothyroidism. Calcium (Choice A) is important for bone health but is not directly related to thyroid function. Vitamin C (Choice C) is essential for the immune system and skin health but does not play a significant role in thyroid function. Iron (Choice D) is vital for red blood cell production and oxygen transport but is not specifically relevant to hypothyroidism.
After undergoing a pericardiocentesis, which interventions should the nurse implement?
- A. Monitor vital signs every 15 minutes for the first hour
- B. Evaluate the client's cardiac rhythm
- C. Record the amount of fluid removed as output
- D. All of the above
Correct Answer: D
Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.
Which laboratory data indicate the client's pancreatitis is improving?
- A. The amylase and lipase serum levels are decreased
- B. The white blood cell count (WBC) is decreased
- C. The conjugated and unconjugated bilirubin levels are decreased
- D. The blood urea nitrogen (BUN) serum level is decreased
Correct Answer: A
Rationale: The correct answer is A. Amylase and lipase are enzymes specifically related to pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. White blood cell count (WBC), choices C and D, are not direct markers for pancreatitis improvement. Bilirubin levels, choice C, are more related to liver function rather than pancreatitis. Blood urea nitrogen (BUN) level, choice D, is a marker for kidney function, not pancreatitis.
The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?
- A. Encouraging family discussion of feelings
- B. Accepting the family's experience of anger
- C. Facilitating the use of spiritual practices identified by the family
- D. All of the above
Correct Answer: D
Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.