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The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious propofol side effect. Options A, B, and C are acceptable.
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The physician has prescribed hydralazine (Apresoline) for a client with acute glomerulonephritis. Which finding indicates that the drug is having the desired effect?
- A. The client's appetite has improved.
- B. Creatinine levels have returned to normal.
- C. The client's blood pressure has decreased.
- D. Urinary output is amber in color.
Correct Answer: C
Rationale: Apresoline (hydralazine) is an antihypertensive; therefore, a decrease in blood pressure indicates the medication is working. Answers A, B, and D indicate that the overall condition of the client is improving, but they are not the result of the medication.
A diabetic client has been maintained on Glucophage (metformin) for regulation of his blood glucose levels. Which teaching should be included in the plan of care?
- A. Report changes in urinary pattern.
- B. Allow six weeks for optimal effects.
- C. Increase the amount of carbohydrates in your diet.
- D. Use lotions to treat itching.
Correct Answer: A
Rationale: Metformin can affect kidney function, so changes in urinary patterns should be reported. Optimal effects occur sooner than six weeks , carbohydrates should be balanced, not increased , and itching is not a common side effect .
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units at bedtime. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue in the morning.
- B. Sweating and shakiness at night.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin. Options A, C, and D are less urgent.
The nurse assesses an 18-month-old child brought to the well child clinic for a routine check-up. Which finding would be of most concern to the nurse?
- A. The child can creep up stairs.
- B. The child is not toilet trained.
- C. The child drops objects handed to him.
- D. The child cries when his mother leaves him with a stranger.
Correct Answer: C
Rationale: Dropping objects handed to him suggests motor or neurological issues at 18 months, requiring evaluation. Creeping , not being toilet trained , and stranger anxiety are normal.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropesol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
- A. Raise the side rails on the bed
- B. Place the call bell within reach
- C. Instruct the client to remain in bed
- D. Have the client empty bladder
Correct Answer: D
Rationale: Have the client empty bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A. Note: It is much easier to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can then be carried out more safely.