Nokea
The nurse is preparing to administer a dose of hydralazine (Apresoline) to a client with hypertension. The client’s blood pressure is 90/60 mmHg. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and recheck the blood pressure.
- D. Recheck the blood pressure in 30 minutes.
Correct Answer: B
Rationale: hydralazine is a vasodilator, and a blood pressure of 90/60 mmHg indicates hypotension, so the dose should be withheld
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An infant with a ventricular septal defect is discharged with a prescription for lanoxin elixir 0.01 mg PO q 12 hrs. The bottle is labeled 0.10 mg per 1/2 tsp. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz. of water
Correct Answer: B
Rationale: The calibrated dropper ensures accurate dosing of Lanoxin (digoxin), critical for preventing toxicity in infants.
A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
- A. Colorful crib mobile
- B. Hand-held electronic games
- C. Cars in a plastic container
- D. 30-piece jigsaw puzzle
Correct Answer: A
Rationale: A colorful crib mobile is age-appropriate and safe for a 6-month-old on bed rest, providing visual stimulation.
Which nurse should be assigned to care for the postpartal client with preeclampsia?
- A. The RN with 2 weeks of experience in postpartum
- B. The RN with 3 years of experience in labor and delivery
- C. The RN with 10 years of experience in surgery
- D. The RN with 1 year of experience in the neonatal intensive care unit
Correct Answer: B
Rationale: The RN with labor and delivery experience is best equipped to manage preeclampsia complications in a postpartal client.
A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 beats per minute
- B. A moderate amount of clear fluid
- C. A small amount of greenish fluid
- D. A small segment of the umbilical cord
Correct Answer: B
Rationale: A moderate amount of clear amniotic fluid is expected after an amniotomy, indicating normal rupture of membranes.
A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
- A. Sublimaze (fentanyl)
- B. Pavulon (pancuronium bromide)
- C. Versed (midazolam)
- D. Atarax (hydroxyzine)
Correct Answer: B
Rationale: Pavulon, a neuromuscular blocker, is used to paralyze respiratory muscles in clients fighting the ventilator, ensuring effective ventilation.