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The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
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A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions?
- A. Administer PRN benztropine mesylate (Cogentin) immediately.
- B. Hold the chlorpromazine and notify the medical staff stat.
- C. Place the client in isolation on bedrest in semi-Fowler's position.
- D. Administer acetaminophen 500 mg and place the client on a cooling mattress.
Correct Answer: B
Rationale: Symptoms indicate neuroleptic malignant syndrome, a life-threatening reaction to chlorpromazine. Holding the drug and notifying staff is critical. Options A, C, and D address symptoms but not the cause.
The nurse is caring for a client with a history of tuberculosis.
- A. Which precaution is most appropriate for a client with active tuberculosis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: D
Rationale: Airborne precautions are required for active tuberculosis to prevent transmission via respiratory droplets. Standard, droplet, and contact precautions are insufficient.
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse, and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, a serious side effect of carvedilol, risking reduced perfusion in heart failure. Options B, C, and D are normal: heart rate 70 bpm, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
- A. Slow down the rate of the oxytocin
- B. Turn the woman on her left side
- C. Give the woman oxygen
- D. Stop the oxytocin
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.