Nokea
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?
- A. Heart rate
- B. Neurologic status
- C. Urine output
- D. Blood pressure
Correct Answer: D
Rationale: The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.
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The nurse is caring for a client with a history of alcoholism.
- A. Which laboratory finding is most concerning for a client with chronic alcoholism?
- B. Serum potassium of 3.2 mEq/L.
- C. Blood urea nitrogen of 18 mg/dL.
- D. Hemoglobin of 13.5 g/dL.
- E. Aspartate aminotransferase (AST) of 150 U/L.
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L indicates hypokalemia, a life-threatening complication in chronic alcoholism due to poor nutrition and diuretic effects of alcohol, risking arrhythmias. Elevated AST reflects liver damage, but hypokalemia is more immediately dangerous.
Which of the following statements, if made by the family, would indicate to the nurse a need for further teaching?
- A. We will need to learn other ways to communicate with each other.'
- B. My father will require a special kind of tube in his neck for his airway.'
- C. My husband will require a feeding tube for several months.'
- D. My dad may develop some difficulty with taste and smell after the surgery.'
Correct Answer: C
Rationale: Strategy: 'Further teaching is necessary' indicates an incorrect response. (1) will communicate in writing initially, then artificial larynx or esophageal speech (2) will require laryngectomy tube to prevent scar tissue contracture (3) correct-requires nutritional support for 10 days until wound heals, then gradually resumes oral intake (4) common with total laryngectomy
While awaiting orders from the physician, the nurse should
- A. initiate measures to transfer the client to a tuberculosis unit.
- B. institute measures to initiate airborne precautions.
- C. arrange for all of the client's personal effects to be decontaminated.
- D. notify the client's family that they have been exposed to a contagious disease.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
The nurse is caring for a client with a history of diabetes insipidus.
- A. Which symptom is expected in a client with diabetes insipidus?
- B. Weight gain and edema.
- C. Polyuria and thirst.
- D. Hypotension and bradycardia.
- E. Hyperglycemia and fatigue.
Correct Answer: B
Rationale: Polyuria and thirst result from diabetes insipidus due to insufficient antidiuretic hormone, leading to excessive water loss. Weight gain, edema, hypotension, and hyperglycemia are unrelated.
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Tachycardia
- C. Ataxia
- D. Hypotension
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.