Nokea
The nurse is caring for a client who was admitted following a motor vehicle accident. The client's blood pressure one hour ago was 118/76, and pulse was 80; now the blood pressure is 90/60, and pulse is 98. What action should the nurse take initially?
- A. Continue to monitor the blood pressure
- B. Ask another nurse to check the blood pressure reading
- C. Elevate the client's legs
- D. Call the physician
Correct Answer: D
Rationale: A significant drop in blood pressure with increased pulse suggests shock or bleeding, requiring immediate physician notification. Monitoring, rechecking, or leg elevation delays care.
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Lithium carbonate is prescribed for an adult. The nurse knows the client is most likely to have which condition?
- A. Depression
- B. Mania
- C. Schizophrenia
- D. Paranoia
Correct Answer: B
Rationale: Lithium carbonate is primarily used to stabilize mood in bipolar disorder, particularly for mania.
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I).
- A. What should the nurse caution the client about to prevent dumping syndrome post-gastrectomy?
- B. Sit up for at least 30 minutes after eating.
- C. Avoid fluids between meals.
- D. Increase the intake of high-carbohydrate foods.
- E. Avoid eating large meals that are high in simple sugars and liquids.
Correct Answer: D
Rationale: To prevent dumping syndrome, the client should avoid large meals high in simple sugars and liquids, which can cause rapid gastric emptying. The client should recline after meals, drink fluids between meals, and reduce carbohydrate intake to stabilize digestion.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
A client is being followed in the rape-crisis clinic one week after being assaulted. The client is currently taking Xanax 0.25 mg PO q6h for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication?
- A. I can take it whenever I feel upset.
- B. I should not take this with anything but water.
- C. I guess I need to stop drinking white wine.
- D. This medication will help me forget and go on.
Correct Answer: C
Rationale: Alcohol, including white wine, potentiates Xanax’s sedative effects, increasing risks. Avoiding it shows understanding. Options A, B, and D are incorrect.
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.