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The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
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A client diagnosed with diabetes mellitus is at 36 weeks' gestation. The client has had weekly reactive nonstress tests for the last 3 weeks. This week, the nonstress test was nonreactive after 40 minutes. Based on these results, the nurse should prepare the client for which intervention?
- A. A contraction stress test
- B. Immediate induction of labor
- C. Hospitalization with continuous fetal monitoring
- D. A return appointment in 2 days to repeat the nonstress test
Correct Answer: A
Rationale: A nonreactive nonstress test after 40 minutes indicates that the fetus did not show the expected heart rate accelerations, which may suggest fetal compromise, particularly in a high-risk pregnancy such as one with diabetes mellitus. The next step is typically a contraction stress test to further assess fetal well-being by evaluating the fetal heart rate response to uterine contractions. Immediate induction or hospitalization may be premature without further evaluation, and repeating the nonstress test in 2 days delays necessary assessment.
The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
- A. Nebulizer
- B. Ambu bag
- C. Suction equipment
- D. Incisional splinting pillow
Correct Answer: D
Rationale: The use of an incisional splint such as a 'cough pillow' can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.
A client prescribed lithium carbonate for the treatment of bipolar disorder has a medication blood level of 1.6 mEq/L (1.6 mmol/L). Which assessment question should the nurse ask to determine whether the client is experiencing signs of lithium toxicity associated with this level?
- A. Do you hear ringing in your ears?
- B. Have you noted that your vision is blurred?
- C. Have you fallen recently because you are dizzy?
- D. Have you been experiencing any nausea, vomiting, or diarrhea?
Correct Answer: D
Rationale: Normal lithium levels are between 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). One of the most common early signs of lower level lithium toxicity is gastrointestinal (GI) disturbances such as nausea, vomiting, or diarrhea. The assessment questions in options 1, 2, and 3 are related to the findings in lithium toxicity at higher levels.
The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse should document that the treatment was effective if which finding was present? Select all that apply.
- A. The client is sleeping soundly.
- B. The client is awake and talking.
- C. Respiratory rate is 26 breaths/minute.
- D. The client's heart rate is 84 beats/minute.
- E. Carboxyhemoglobin levels are less than 5%.
- F. The heart monitor shows normal sinus rhythm.
Correct Answer: D,E,F
Rationale: Normal carboxyhemoglobin levels are less than 5% for a nonsmoking adult. Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.
The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study should the nurse review for data about the client's acid-base balance?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Phosphorus
Correct Answer: B
Rationale: A client with late-stage salicylate poisoning is at risk for metabolic acidosis because acetylsalicylic acid increases the client's hydrogen ion (H+) concentration, decreases the pH, and creates a bicarbonate deficit. Hyperkalemia develops as the body attempts to compensate for the influx of H+ by moving H+ into the cell and potassium out of the cell; thus, potassium accumulates in the extracellular space. Clinical manifestations of metabolic acidosis include the clinical indicators of hyperkalemia, including hyperpnea, central nervous system depression, twitching, and seizures. Options 1, 3, and 4 are not primary concerns.