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The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: Hypotension (90/60 mmHg) is a serious carvedilol side effect, risking perfusion in heart failure. Options B, C, and D are normal.
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An adult client with a nasogastric tube has an order for acetaminophen (Tylenol) 650 mg PRN for a temperature greater than 101°F (38.3°C).
Which of the following measures should be included by the nurse when administering this medication?
- A. The tablets should be swallowed carefully with sips of water.
- B. The medication should be withheld until the nasogastric tube is removed.
- C. Placement of the nasogastric tube should be checked prior to giving the medication.
- D. Powdered medication should be used and mixed with water to form a solution.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is NPO, so nothing should be administered orally (2) medication should not be withheld (3) correct-liquid acetaminophen may be administered via the nasogastric tube after tube placement has been checked; tube placement should be checked before anything is instilled (4) Tylenol does not come powdered
A 28-year-old primigravida with pregestational diabetes visits the clinic 6 weeks gestation. Which of the following statements indicates that she understands the nurse's teaching regarding her insulin needs during pregnancy?
- A. As the baby grows, I will need more insulin because the baby will not be able to make insulin.
- B. Changes in hormone levels will make my body more resistant to insulin, so I will need more insulin as the pregnancy progresses.
- C. As the baby grows, I will need less insulin because the baby uses up any extra glucose.
- D. If I maintain an adequate balance of diet and exercise, my insulin requirements will be the same.
Correct Answer: B
Rationale: Pregnancy hormones increase insulin resistance, requiring more insulin as pregnancy progresses in diabetic patients. Other statements are incorrect regarding insulin dynamics.
The nurse is caring for a client with a history of tuberculosis.
- A. Which precaution is most appropriate for a client with active tuberculosis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: D
Rationale: Airborne precautions are required for active tuberculosis to prevent transmission via respiratory droplets. Standard, droplet, and contact precautions are insufficient.
A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding.
- A. Which statement by a woman at 38-weeks gestation with vaginal bleeding suggests placenta previa?
- B. I feel fine, but the bleeding scares me.'
- C. I’ve been more nauseated during the past few weeks.'
- D. The bleeding started after I carried four bags of groceries.'
- E. I’ve been having severe abdominal cramps.'
Correct Answer: A
Rationale: Placenta previa is characterized by painless vaginal bleeding, as the placenta covers the cervical os. The statement ‘I feel fine, but the bleeding scares me’ indicates bleeding without pain, consistent with placenta previa. Nausea, activity-related bleeding, or cramps suggest other causes like abruptio placentae.
A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions?
- A. Administer PRN benztropine mesylate (Cogentin) immediately.
- B. Hold the chlorpromazine and notify the medical staff stat.
- C. Place the client in isolation on bedrest in semi-Fowler's position.
- D. Administer acetaminophen 500 mg and place the client on a cooling mattress.
Correct Answer: B
Rationale: Symptoms indicate neuroleptic malignant syndrome, a life-threatening reaction to chlorpromazine. Holding the drug and notifying staff is critical. Options A, C, and D address symptoms but not the cause.