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When obtaining an admission history for a client who is at 9 weeks gestation, the client states, 'I had a miscarriage 2 years ago.' Which information is most important for the nurse to obtain?
- A. How long was your previous pregnancy?
- B. How long did it take for you to become pregnant after your miscarriage?
- C. Was your miscarriage during the first trimester?
- D. Do you have any children now?
Correct Answer: A
Rationale: The correct answer is A. Understanding the duration of the previous pregnancy helps assess the client's obstetric history. Choice B focuses on the time it took to conceive after the miscarriage, which is less relevant at this point. Choice C asks about the timing of the miscarriage rather than the duration of the previous pregnancy. Choice D inquires about the current status of having children, which is not directly related to the client's obstetric history.
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A client is receiving a low dose of dopamine (Intropin) IV for the treatment of hypotension. Which indicator reflects that the medication is having the desired effect?
- A. Increased heart rate
- B. Increased urinary output
- C. Increased blood pressure
- D. Increased respiratory rate
Correct Answer: C
Rationale: Increased blood pressure is the desired effect of administering dopamine (Intropin) to treat hypotension. Dopamine acts by stimulating adrenergic receptors, leading to vasoconstriction and increased cardiac output. This results in an elevation of blood pressure. Choices A, B, and D are incorrect as they do not directly reflect the therapeutic action of dopamine in treating hypotension. Increased heart rate may indicate the body compensating for low blood pressure, increased urinary output is more related to kidney function, and increased respiratory rate is often seen in response to respiratory issues, not the action of dopamine on hypotension.
The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?
- A. Vastus lateralis
- B. Deltoid
- C. Ventrogluteal
- D. Dorsogluteal
Correct Answer: A
Rationale: The vastus lateralis is the preferred site for IM injections in infants due to muscle development. In infants under 1 year old, the vastus lateralis muscle in the thigh is often used for IM injections due to its size and development. The deltoid muscle is typically used for adults, and the ventrogluteal and dorsogluteal sites are more commonly used for older children and adults. Therefore, the best choice for administering an IM injection to a 6-month-old child is the vastus lateralis.
A nurse is planning care for a client who has a new prescription for metoprolol (Lopressor). Which assessment finding should the nurse report to the healthcare provider before administering the medication?
- A. Heart rate of 50 beats per minute
- B. Blood pressure of 90/60 mm Hg
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 99°F (37.2°C)
Correct Answer: A
Rationale: A heart rate of 50 beats per minute is a concerning finding that should be reported before administering metoprolol. Metoprolol is a beta-blocker that can further lower the heart rate, so a heart rate of 50 bpm indicates potential bradycardia, which is a contraindication for administering this medication. Choices B, C, and D are within normal ranges and do not pose immediate concerns related to metoprolol administration.
The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
- A. Tachycardia, mental status change, and low urine output
- B. Warm skin, hypertension, and constricted pupils
- C. Bradycardia, hypotension, and respiratory acidosis
- D. Mottled skin, tachypnea, and hyperactive bowel sounds
Correct Answer: A
Rationale: The correct answer is A: Tachycardia, mental status change, and low urine output are early signs of shock. Tachycardia is the body's compensatory mechanism to maintain perfusion, mental status changes can indicate decreased cerebral perfusion, and low urine output reflects poor renal perfusion. Choices B, C, and D are incorrect. Warm skin, hypertension, and constricted pupils are not typical findings in the early stages of shock. Bradycardia, hypotension, and respiratory acidosis are more indicative of late-stage shock. Mottled skin, tachypnea, and hyperactive bowel sounds can be seen in various conditions but are not specific early signs of shock.
A client with chronic renal failure is being discharged with a prescription for erythropoietin (Epogen). Which statement indicates that the client understands the action of this medication?
- A. It helps my body make red blood cells
- B. It helps prevent infections
- C. It helps my kidneys excrete excess fluid
- D. It helps me breathe easier
Correct Answer: A
Rationale: The correct answer is A: 'It helps my body make red blood cells.' Erythropoietin is a medication that stimulates the production of red blood cells in the body. Clients with chronic renal failure often develop anemia due to decreased erythropoietin production by the kidneys. This medication helps address that issue by increasing red blood cell production. Choices B, C, and D are incorrect because erythropoietin does not prevent infections, help kidneys excrete excess fluid, or assist with breathing; its primary action is to boost red blood cell production.