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The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply.
- A. Administration of oxygen
- B. Administration of a 2nd dose of naloxone
- C. Discontinuation of pain medication
- D. Initiation of a rapid response or code team
- E. Monitoring of respiratory rate
Correct Answer: A,B,E
Rationale: Recurrent unresponsiveness suggests opioid re-narcotization, requiring oxygen, a second naloxone dose, and respiratory monitoring. Discontinuing pain medication is premature, and rapid response is not yet indicated.
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A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
An adult is being discharged on a low-sodium, low-fat diet. Which menu, if selected by the client, indicates an understanding of the diet?
- A. Hamburger with fries, apple pie, milkshake
- B. Tossed salad with vinaigrette dressing, baked skinny chicken, applesauce
- C. Steak, corn on the cob, fruit salad
- D. Fried shrimp, coleslaw, strawberry shortcake
Correct Answer: B
Rationale: Tossed salad, baked skinless chicken, and applesauce are low in sodium and fat, aligning with the prescribed diet.
The nurse is talking with a client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? Select all that apply.
- A. Anticipate experiencing light fetal movements around 16 to 20 weeks gestation
- B. Increase your consumption of iron-rich foods like meat and dried fruit
- C. Try to gain about 3 lb (1.4 kg) each week if your prepregnancy BMI was normal
- D. Expect to have an abdominal ultrasound scheduled to check fetal anatomy
- E. Plan to be screened for gestational diabetes mellitus around 24 to 28 weeks gestation
Correct Answer: A,B,D,E
Rationale: Fetal movement, iron intake, anatomy ultrasound, and diabetes screening are standard second-trimester recommendations. Weight gain should be about 1 lb/week for normal BMI, not 3 lb.
When monitoring an infant with a left-to-right sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply.
- A. Clubbing of fingertips
- B. Cyanosis when crying
- C. Diaphoresis during feedings
- D. Heart murmur
- E. Poor weight gain
Correct Answer: C,D,E
Rationale: Left-to-right shunts (e.g., VSD) cause pulmonary overcirculation, leading to diaphoresis, murmurs, and poor weight gain. Clubbing and cyanosis are more typical of right-to-left shunts.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client’s current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: Medication adherence is the most critical factor to assess in uncontrolled hypertension (170/94 mm Hg), as non-compliance is a common cause. Stress, diet, and smoking are secondary.