Nokea
The nurse is caring for a client with a history of a myocardial infarction. The client is receiving TPA (alteplase). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Hyperthermia
Correct Answer: A
Rationale: TPA, a thrombolytic, increases bleeding risk by dissolving clots. Monitoring for bleeding (e.g., gums, urine) is critical. Hypertension, hypoglycemia, and hyperthermia are not primary concerns.
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A client with a history of ovarian cancer is admitted with complaints of abdominal swelling. The nurse should give priority to:
- A. Monitoring for ascites
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Abdominal swelling in ovarian cancer often indicates ascites, so monitoring for ascites is the priority to guide treatment.
The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?
- A. Mix the drug with normal saline solution.
- B. Administer the drug over 4-6 hours.
- C. Hydrate with IV fluids two hours before the infusion is scheduled to begin.
- D. Premedicate the client with ordered acetaminophen (Tylenol) and diphenhydramine (Benadryl).
Correct Answer: A
Rationale: Amphotericin B should be mixed with D5W, not normal saline, due to stability issues. Slow infusion (B), hydration (C), and premedication (D) are standard practices.
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Administer her next dosage of lithium, and then call the physician.
- B. Withhold her lithium, and report her symptoms to the physician.
- C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
- D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Correct Answer: B
Rationale: The client has lithium toxicity, and the nurse must withhold further dosages. Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level.
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the overall time of the labor process
- B. Prolongs the client's first stage of labor
- C. Decreases the time of the client's first stage of labor
- D. Prolongs the client's third stage of labor
Correct Answer: B
Rationale: The left occipital posterior position presents a larger fetal head diameter, increasing pressure on sacral nerves and prolonging the first stage of labor due to slower fetal descent.
What is the appropriate nursing action for a child with increased intracranial pressure?
- A. Head of bed elevated 45 degrees with child's head maintained in a neutral position
- B. Child lying flat
- C. Head turned to side
- D. Frequent visitation for stimulation
Correct Answer: A
Rationale: Elevating the head of the bed to 45 degrees with a neutral head position promotes venous drainage, reducing intracranial pressure.