Nokea
The nurse is caring for a client who is receiving a continuous IV infusion of nitroglycerin for chest pain. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 100/60 mmHg
- B. Heart rate of 80 bpm
- C. Respiratory rate of 18 breaths/min
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: Hypotension (100/60 mmHg) is a serious nitroglycerin side effect, risking inadequate perfusion. Options B, C, and D are normal findings.
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A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct Answer: D
Rationale: Do not administer pain medication or start a central line without MD orders.
A diabetic client asks the nurse why the provider ordered a glycosylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
- A. Provides a more precise blood glucose value than self-monitoring
- B. Is performed to detect complications of diabetes
- C. Measures circulating levels of insulin
- D. Reflects an average blood sugar for several months
Correct Answer: D
Rationale: Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 2-3 months and can be used to monitor client adherence to the therapeutic regimen.
The nurse is preparing to change the dressing of a client with a venous access device. Because it is the first time the nurse has performed the skill, he reads the unit policy manual and asks another nurse how to best perform the dressing change. The skill level of the nurse at this time is best described as:
- A. Novice
- B. Proficient
- C. Competent
- D. Expert
Correct Answer: A
Rationale: A nurse performing a skill for the first time, relying on guidelines and assistance, is a novice. Higher levels require experience and independence.
The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which of the following plans would be a priority to meet the needs of this father?
- A. Encourage the father to call his wife after work.
- B. Instruct the father about visiting policy and suggest AM visitation.
- C. Adjust visiting hours to meet the new parents' needs.
- D. Present a change of visiting hours to the appropriate hospital committee.
Correct Answer: C
Rationale: Adjusting visiting hours accommodates the father’s evening shift, enabling bonding with his newborn, a priority for family-centered care. Options A and B are less flexible, and option D is a long-term solution, not immediate.
After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states 'I am so confused. I lose my money. I just can't remember telephone numbers.' The most therapeutic response for the nurse to make is
- A. You were seriously ill and needed the treatments.'
- B. Don't get upset. The confusion will clear up in a day or two.'
- C. It is to be expected since most clients have the same results.'
- D. I can hear your concern and that your confusion is upsetting to you.'
Correct Answer: D
Rationale: Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed.