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The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client’s pulse to be 144. The nurse’s priority action should be to
- A. withhold the medication.
- B. decrease the dose by half.
- C. administer the medication.
- D. wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure
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The nurse is caring for a client who abuses narcotics. The client is exhibiting a respiratory rate of 10 and dilated pupils. Which drug would the nurse expect to administer?
- A. Meperidine (Demerol)
- B. Naloxone (Narcan)
- C. Chlordiazepoxide (Librium)
- D. Haloperidol (Haldol)
Correct Answer: B
Rationale: Respiratory depression (rate of 10) and dilated pupils suggest opioid overdose. Naloxone (Narcan) is the antidote to reverse opioid toxicity.
The nurse is supervising a student nurse on the oncology unit who is providing care for a client with neutropenic precautions. Which action by the student nurse requires intervention by the supervising nurse?
- A. Vital signs, including temperature, are monitored every 4 hours.
- B. The student nurse inspects the client's mouth at least every 8 hours.
- C. The student nurse delivers a potted plant to the room sent by the client's family.
- D. The student nurse washes her hands before performing client care or touching client belongings.
Correct Answer: C
Rationale: Potted plants pose an infection risk (e.g., mold) for neutropenic clients and are prohibited. Other actions are appropriate.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for sensory perception alterations, especially during stressful procedures like surgery.
The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:
- A. A false elevation
- B. A false low reading
- C. A blood pressure reading that is correct
- D. A subnormal finding
Correct Answer: A
Rationale: A blood pressure cuff that is too small will result in a false elevation of the blood pressure reading due to increased pressure on the arm.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.