Nokea
The nurse is caring for an adult who is receiving diphenoxylate hydrochloride with atropine sulfate (Lomotil) qid. What nursing assessment is essential while the client is receiving this medication?
- A. Monitor blood pressure hourly
- B. Assess respirations before administering drug
- C. Measure hourly urine output
- D. Do neuro checks every two hours
Correct Answer: B
Rationale: Lomotil can cause respiratory depression due to its opioid component, requiring respiratory assessment before administration.
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The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?
- A. Estrogen replacement therapy
- B. 10% less than ideal body weight
- C. Hypersensitivity to heparin
- D. History of hepatitis
Correct Answer: A
Rationale: Estrogen increases the hypercoagulability of the blood and increases the risk for development of thrombophlebitis.
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply.
- A. I don't plan on eating any more frozen meals.'
- B. I plan to take my diuretic pill in the morning.'
- C. I will weigh myself at least every other day.'
- D. I'm going to look into joining a cardiac rehabilitation program.'
- E. Ibuprofen works best for me when I have pain.'
Correct Answer: E
Rationale: Ibuprofen can cause fluid retention, worsening heart failure, and requires further teaching. Avoiding frozen meals , morning diuretic , regular weighing , and cardiac rehab are appropriate.
The nurse is to administer an iron injection to an adult. How should this be administered?
- A. Subcutaneous in the arm
- B. Intradermal in the forearm
- C. Intramuscular in the deltoid
- D. Z track intramuscular in the gluteal
Correct Answer: D
Rationale: Iron injections are given via Z-track intramuscular in the gluteal muscle to prevent leakage and skin staining, ensuring deep muscle administration.
The nurse in the emergency department is caring for a client who sustained blunt force head trauma and is experiencing blurry vision. The nurse should suspect the client has sustained injury to the
- A. temporal lobe
- B. occipital lobe
- C. parietal lobe
- D. frontal lobe
Correct Answer: B
Rationale: Blurry vision post-head trauma suggests injury to the occipital lobe , which processes visual information. Temporal , parietal , and frontal lobes manage other functions.
The nurse is collecting data on a client with hypertension and essential tremor who received the first dose of propranolol 2 hours ago. Which assessment is most concerning to the nurse?
- A. Client reports a headache
- B. Current blood pressure is 160/88 mm Hg
- C. Heart rate has decreased from 70/min to 60/min
- D. Slight wheezes auscultated during inspiration
Correct Answer: D
Rationale: Wheezing post-propranolol is concerning for bronchospasm, a serious side effect in a patient with no known respiratory history. Headache , elevated BP , and mild heart rate decrease are less urgent.