Nokea
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth
- B. Blurred vision and eye pain
- C. Occasional cough
- D. Mild nasal congestion
Correct Answer: B
Rationale: Blurred vision and eye pain suggest acute angle-closure glaucoma, a rare but serious ipratropium side effect. Options A, C, and D are less urgent: dry mouth is common, cough is expected, and congestion is nonspecific.
You may also like to solve these questions
The nurse is caring for a client with a history of epilepsy who is receiving carbamazepine (Tegretol) 200 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. White blood cell count of 3,000/mm^3.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A white blood cell count of 3,000/mm^3 indicates leukopenia, a serious side effect of carbamazepine, increasing infection risk and requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
An upset client says to the nurse, 'Where did you learn to be a nurse? You don't know anything.' How should the nurse respond?
- A. I'm sorry you feel that way.'
- B. I went to a fine nursing school.'
- C. You sound upset.'
- D. Please don't speak to me that way.'
Correct Answer: C
Rationale: Reflecting the client's emotions ('You sound upset') opens therapeutic dialogue, addressing feelings without defensiveness. Other responses escalate or dismiss.
A newly admitted client is exhibiting signs of severe anxiety. She is pacing back and forth and has difficulty concentrating on the nurse's questions. What nursing action is most appropriate at this time?
- A. Tell the client to sit down and get control of herself
- B. Leave the room until she regains control
- C. Whisper to her that everything will be all right
- D. Attend to her behavior and direct her to a quiet area
Correct Answer: D
Rationale: Directing the client to a quiet area reduces stimuli, helping manage severe anxiety. Commands, leaving, or whispering are ineffective or dismissive.
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.
A client before administration of captopril (Capoten).
The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's
- A. apical pulse for 60 seconds.
- B. blood pressure.
- C. urine output.
- D. temperature.
Correct Answer: B
Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication