Nokea
Which medication should the nurse withhold if the client's blood pressure is 88/50?
- A. Rosuvastatin (Crestor)
- B. Enalapril (Vasotec)
- C. Digoxin (Lanoxin)
- D. Clopidogrel (Plavix)
Correct Answer: B
Rationale: Enalapril (Vasotec) is the correct answer. It is an angiotensin-converting enzyme (ACE) inhibitor that can further lower blood pressure. Given that the client's blood pressure is already low at 88/50, administering Enalapril could exacerbate hypotension and compromise perfusion to vital organs. Rosuvastatin (Crestor), Digoxin (Lanoxin), and Clopidogrel (Plavix) are not contraindicated in the context of low blood pressure and may be administered safely.
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The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. Which assessment finding is consistent with a flail chest?
- A. Biot's respirations
- B. Sucking sounds during respirations
- C. Paradoxical chest wall movement
- D. Hypotension and bradycardia
Correct Answer: C
Rationale: The correct assessment finding consistent with a flail chest is paradoxical chest wall movement. This occurs when a segment of the chest wall moves in the opposite direction to the rest of the chest during respiration. Biot's respirations (Choice A) are a pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. Sucking sounds during respirations (Choice B) may indicate air entering or leaving the chest cavity through a wound. Hypotension and bradycardia (Choice D) may be present due to other factors such as shock, but they are not specific to a flail chest.
The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?
- A. 15 seconds
- B. 3 minutes
- C. 5 minutes
- D. 15 minutes
Correct Answer: B
Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.
A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DKA). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones. Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis. Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction. Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis. Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.
The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?
- A. Client with irritable bowel syndrome
- B. Family history of colon polyps
- C. Client with cirrhosis of the liver
- D. History of colon surgery
Correct Answer: B
Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time?
- A. Warm the room
- B. Submerge the hand in warm water
- C. Order a K pad and apply to hand
- D. Have the client exercise the fingers to increase blood flow
Correct Answer: A
Rationale: The correct action for the nurse to take when caring for a burn victim with a skin graft to the hand, exhibiting pale and mottled skin but good capillary refill, is to warm the room. By warming the room, the nurse helps promote circulation and maintain a conducive environment for healing. Submerging the hand in warm water can pose a risk of injury or infection to the graft site. Ordering a K pad and applying it to the hand may not be necessary at this time and could potentially cause harm. Having the client exercise the fingers to increase blood flow is also not recommended as it may interfere with the healing process of the skin graft.