Nokea
What instruction should be provided to a client with a history of myocardial infarction (MI) who is prescribed nitroglycerin?
- A. Take nitroglycerin with food to avoid stomach upset.
- B. Store nitroglycerin tablets in a dark, glass container.
- C. Swallow nitroglycerin tablets whole without chewing.
- D. Discontinue the medication if a headache occurs.
Correct Answer: B
Rationale: The correct answer is B because nitroglycerin tablets should be stored in a dark, glass container to protect them from light and moisture, which could decrease their effectiveness. Storing them in any other container could lead to degradation of the medication.
Choice A is incorrect because nitroglycerin should be taken sublingually, not with food. Choice C is incorrect because nitroglycerin should be placed under the tongue to be absorbed quickly, not swallowed whole. Choice D is incorrect because experiencing a headache is a common side effect of nitroglycerin and does not indicate that the medication should be discontinued.
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A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
- A. Refuses to eat her favorite meals at home.
- B. Drinks more soft drinks than previously.
- C. Voids only one or two times per day.
- D. Gained 10 pounds within one month.
Correct Answer: B
Rationale: The correct answer is B because increased thirst and drinking more fluids than usual is a common symptom of diabetes mellitus due to high blood sugar levels causing dehydration. Refusing to eat favorite meals (choice A) is not a typical symptom. Voids only one or two times per day (choice C) is more related to urinary issues than diabetes. Gaining 10 pounds within one month (choice D) is not a specific symptom of diabetes and can be attributed to various factors.
A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct Answer: D
Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.
A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?
- A. Administer sargramostim (Leukine, Prokine).
- B. Infuse PRBC and platelet transfusions.
- C. Give parenteral prophylactic antibiotics.
- D. Maintain a protective isolation environment.
Correct Answer: D
Rationale: The correct answer is D: Maintain a protective isolation environment. During bone marrow repopulation after transplantation, the client is at high risk of infection due to compromised immune function. By maintaining a protective isolation environment, the nurse can minimize the risk of exposure to pathogens that could lead to infections. This intervention helps prevent potential complications and supports the client's recovery.
Rationale for other choices:
A: Administering sargramostim may enhance white blood cell production but does not directly address the risk of infection during bone marrow repopulation.
B: Infusing PRBC and platelet transfusions may be necessary for managing anemia and thrombocytopenia but does not address the priority of infection prevention.
C: Giving prophylactic antibiotics may be beneficial in some cases, but maintaining a protective isolation environment is the priority to reduce the risk of infection in this immunocompromised client.
A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula for hemodialysis. Which finding should the nurse report to the healthcare provider immediately?
- A. No bruit or thrill over the AV fistula.
- B. Redness at the site of the AV fistula.
- C. Client's complaint of pain at the AV fistula site.
- D. Swelling of the hand on the side of the AV fistula.
Correct Answer: A
Rationale: The correct answer is A: No bruit or thrill over the AV fistula. A bruit and thrill indicate proper blood flow through the AV fistula, essential for successful hemodialysis. Absence of these sounds can indicate AV fistula malfunction, leading to inadequate dialysis. Redness, pain, and swelling are common complications of AV fistula placement but do not require immediate reporting unless severe or accompanied by other symptoms like fever or pus drainage. Reporting the absence of a bruit or thrill promptly allows for timely intervention to prevent complications and ensure effective dialysis.
Which client's laboratory value requires immediate intervention by a nurse?
- A. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams.
- B. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday.
- C. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.
- D. A client with cancer who has an absolute neutrophil count < 500 today and had 2,000 yesterday.
Correct Answer: D
Rationale: The correct answer is D because a client with an absolute neutrophil count < 500 is at high risk for serious infections due to severe neutropenia. Neutrophils are crucial for fighting infections, and a low count puts the client at immediate risk. Therefore, intervention is required to prevent life-threatening complications.
Choice A: A hemoglobin of 7 grams in a client with GI bleeding receiving a blood transfusion indicates anemia, but it does not require immediate intervention unless the client is symptomatic.
Choice B: A fasting glucose of 190 mg/dl in a client with pancreatitis is elevated but does not require immediate intervention unless the client is symptomatic or experiencing complications.
Choice C: A bilirubin level 4 times the normal value in a jaundiced client with hepatitis is concerning but does not require immediate intervention unless there are signs of severe liver dysfunction or complications.