Nokea
The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:
- A. Hypotension
- B. Tachycardia
- C. Hyperglycemia
- D. Fever
Correct Answer: A
Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.
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Which of the following nursing care goals has the highest priority for a child with epiglottitis?
- A. Sleep or lie quietly 10 hr/day.
- B. Consume foods from all four food groups.
- C. Be afebrile throughout her hospital stay.
- D. Participate in play activities 4 hr/day.
Correct Answer: A
Rationale: Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
The client is admitted with a diagnosis of gestational diabetes. Which intervention is most appropriate?
- A. Monitor blood glucose levels
- B. Administer tocolytics
- C. Monitor fetal heart tones
- D. All of the above
Correct Answer: D
Rationale: Gestational diabetes requires blood glucose monitoring to maintain control fetal heart tone monitoring to assess fetal well-being and potentially other interventions. Tocolytics are not indicated unless preterm labor occurs.
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Maintaining seizure precautions
- B. Restricting fluid intake
- C. Increasing sensory stimuli
- D. Applying ankle and wrist restraints
Correct Answer: A
Rationale: These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. Fluid intake should be increased to prevent dehydration. Environmental stimuli should be decreased to prevent precipitation of seizures. Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
The nurse is caring for a client with B-thalassemia major. Which therapy is used to treat B-thalassemia major?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: B-thalassemia major causes severe anemia due to defective hemoglobin synthesis, requiring frequent blood transfusions to maintain hemoglobin levels. IV fluids, oxygen, and iron therapy (which can cause overload) are not primary treatments.
Which information should be given to the client using a TENS unit?
- A. Electrocution may occur if you use water with this unit.'
- B. Skin irritation may occur with prolonged use of the unit.'
- C. The unit can be placed anywhere on the body without fear of adverse reactions.'
- D. A cream or lotion should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Prolonged use of a TENS unit can cause skin irritation due to electrode adhesion or electrical stimulation. Electrocution is not a risk with battery-operated units, placement requires specific guidance, and lotions may interfere with electrode contact.