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A 35-year-old woman one-day postpartum receiving butorphanol tartrate (Stadol) 1 mg IM.
Which of the following actions is MOST important for the nurse to take after administering the medication?
- A. Observe the woman for sedation.
- B. Monitor the vital signs.
- C. Assess for visual disturbances.
- D. Evaluate fluid status.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice and how it relates to Stadol. (1) causes sedation, but not most important (2) correct-decreases rate and depth of respirations (3) diplopia and blurred vision are side effects, but not most important (4) not side effect of medication
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A toddler with Tetralogy of Fallot is hospitalized with a diagnosis of pneumonia. During the nursing assessment, the child develops a hypoxic episode. The nurse should:
- A. Provide the child his favorite toy.
- B. Place the child in a supine position.
- C. Pick the child up and comfort him.
- D. Place the child in knee chest position.
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting in Tetralogy of Fallot during hypoxia. Toys or comforting do not address hypoxia. Supine position may worsen shunting.
Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include
- A. the time and circumstances under which the rash was noted.
- B. the explanation given to the client and family of the reason for the rash.
- C. notation on an allergy list and notification of the doctor.
- D. the need for application of corticosteroid cream to decrease inflammation.
Correct Answer: C
Rationale: suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
The nurse is caring for clients in the prenatal clinic. The nurse would be MOST concerned if a diabetic client in the third trimester makes which of the following statements?
- A. I am taking less insulin now than I did two months ago.
- B. I am eating a large bedtime snack.
- C. I walk 15 minutes after lunch every day.
- D. I check my blood sugar two hours after each meal.
Correct Answer: A
Rationale: Decreased insulin needs in the third trimester suggest placental dysfunction, as placental hormones typically increase insulin resistance. Options B, C, and D are appropriate: bedtime snacks prevent hypoglycemia, exercise after meals manages glucose, and postprandial checks monitor hyperglycemia.
An 87-year-old woman is admitted to the acute care hospital for heart failure. The nurse asks about the client's signs and symptoms and obtains vital signs. Considering the client's age, what additional question is most important for the nurse to ask?
- A. How do you manage your bowels?
- B. When was your last menstrual period?
- C. What are your favorite foods?
- D. When was your last tetanus shot?
Correct Answer: D
Rationale: Elderly patients are at risk for tetanus due to waning immunity; assessing vaccination status is critical for infection prevention.