Nokea
The nurse is evaluating the client's pulmonary artery pressure (PAP). The nurse is aware that PAP evaluates:
- A. Pressure in the left ventricle
- B. Systolic, diastolic, and mean pressure in the pulmonary artery
- C. Pressure in the pulmonary veins
- D. Pressure in the right ventricle
Correct Answer: B
Rationale: Pulmonary artery pressure (PAP), measured via a pulmonary artery catheter, reflects systolic, diastolic, and mean pressures in the pulmonary artery, indicating right ventricular function and pulmonary circulation status.
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A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
- A. Dims the lights in her room
- B. Encourages her to breathe slowly and deeply
- C. Offers sips of warm liquids
- D. Places a large, soft pillow under her head
Correct Answer: A
Rationale: The discomfort of photophobia is alleviated by dimming the lights. Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
The nurse is caring for a client with a history of a seizure disorder who is receiving Carbamazepine (Tegretol). The nurse should monitor the client for:
- A. Leukopenia
- B. Hypotension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Carbamazepine can cause leukopenia, requiring monitoring of white blood cell counts. Hypotension, hyperglycemia, and weight gain are not primary side effects.
A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:
- A. Should not be there on the second day
- B. Will stop when the Foley catheter is removed
- C. Is normal and he need not be concerned about it
- D. Can be removed by irrigating the bladder
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases.
The physician has ordered Dilantin (phenytoin) 100 mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
- A. Rapidly with an IV push
- B. With IV dextrose
- C. Slowly over 2-3 minutes
- D. Through a small vein
Correct Answer: C
Rationale: Phenytoin must be administered slowly (over 2-3 minutes) to prevent cardiovascular complications like hypotension or arrhythmias. It should not be mixed with dextrose or given rapidly.
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
- A. Auditory
- B. Gustatory
- C. Olfactory
- D. Visceral
Correct Answer: B
Rationale: Auditory hallucinations involve sensory perceptions of hearing. Gustatory hallucinations involve sensory perceptions of taste. Olfactory hallucinations involve sensory perceptions of smell. Visceral hallucinations involve sensory perceptions of sensation.