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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A woman is seen in clinic with complaints suggesting cholecystitis or cholelithiasis. What teaching should the nurse expect to reinforce?
- A. Sit up after you eat.
- B. Avoid carbonated beverages.
- C. Avoid caffeine.
- D. Avoid fatty foods.
Correct Answer: D
Rationale: Fatty foods trigger gallbladder contraction, worsening pain in cholecystitis or cholelithiasis; avoiding them reduces symptoms. Sitting up, carbonated drinks, or caffeine are less critical.
A client who had a total thyroidectomy this morning returns to the nursing care unit. How should the nurse position the client?
- A. Semi-sitting
- B. Supine
- C. Prone
- D. Sims'
Correct Answer: A
Rationale: Semi-sitting reduces neck swelling and promotes airway patency post-thyroidectomy. Supine, prone, or Sims' positions increase complications.
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.
A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
- A. Check with case manager on duty about possible police intervention.
- B. Provide an environment of concern and emotional stabilization.
- C. Clean the patient's wounds with normal saline and gauze.
- D. Recommend a good attorney to the patient.
Correct Answer: B
Rationale: Emotional support is what that patient needs most at this point in time.
The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?
- A. The first of every month, because it is easiest to remember'
- B. Right after the period, when your breasts are less tender'
- C. Do the exam at the same time every month'
- D. Ovulation, or mid-cycle is the best time to detect changes'
Correct Answer: B
Rationale: The best time for a breast self-exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.