Nokea
The nurse is caring for a client receiving Theodur (theophylline). Side effects associated with bronchodilators include:
- A. Irritability, rapid pulse, and palpitations
- B. Slow pulse, increased appetite, and sweating
- C. Anxiety, nausea, and increased blood pressure
- D. Drowsiness, vomiting, and decreased blood sugar
Correct Answer: A
Rationale: Theophylline can cause irritability, rapid pulse, and palpitations due to its stimulant effects. Slow pulse , drowsiness , or decreased blood sugar are not typical.
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After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.
The nurse is caring for a client who has a prescription for furosemide 1 mg/kg PO every 8 hours. The client weighs 44 lb (20 kg). The nurse has furosemide oral solution 10 mg/mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: Dose: 1 mg/kg × 20 kg = 20 mg. Solution: 20 mg ÷ 10 mg/mL = 2 mL .
The health care provider (HCP) provides education to an adult client about an upcoming surgical procedure. The client states, 'I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy.' What action should the nurse take?
- A. Ask the client's family member to sign the consent form
- B. Inform the client that the HCP can discuss all questions after surgery
- C. Provide the client with educational materials about low-fat diet options
- D. Reinforce education about the procedure using a visual aid
Correct Answer: C
Rationale: Providing dietary education addresses the client's question directly. Family consent is inappropriate, postponing discussion delays clarification, and procedure education doesn't address diet.
The nurse is preparing to obtain a urine specimen for urinalysis from an 18-month-old client. Which of the following actions should the nurse take?
- A. Perform intermittent straight catheterization to obtain the urine from the client.
- B. Apply an adhesive urine collection bag around the client's genital area.
- C. Ask the parent to obtain the client's urine using a specimen cup
- D. Place a urine dipstick in the client's diaper overnight.
Correct Answer: B
Rationale: An adhesive collection bag is non-invasive and effective for toddlers. Catheterization is invasive, a cup is impractical, and a dipstick is inaccurate.
A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?
- A. Abdominal rigidity and diarrhea
- B. Back pain and urge incontinence
- C. Difficulty swallowing and breathing
- D. Difficulty walking and hand tremor
Correct Answer: C
Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.