Nokea
A client who is receiving hydralazine (Apresoline) q6h has a blood pressure of 90/60.
Which of the following nursing actions would be MOST appropriate?
- A. Withhold the medication.
- B. Check the urinary output.
- C. Administer the medication.
- D. Increase the potassium intake.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. (1) correct-BP of 90/60 is too low for an additional dose of medication, withholding the medication and checking with the doctor is appropriate (2) assessment, appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance
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The nurse evaluates the nutritional intake of a 16-year-old girl at a camp for adolescents. The girl eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the food pyramid, and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height?
- A. Her diet is low in calories and high in iron.
- B. Her diet is low in calories and low in iron.
- C. Her diet is high in calories and low in iron.
- D. Her diet is high in calories and high in iron.
Correct Answer: C
Rationale: 900 × 3 = 2,700 calories/day and women need 1,200-1,500 kcal/day (men need 1,500-1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
- A. Temperature of 102 degrees Fahrenheit
- B. Pulse rate of 98 beats per minute
- C. Respiratory rate of 32
- D. Blood pressure of 90/50
Correct Answer: C
Rationale: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.
The nurse's neighbor complains to the nurse that he feels tired all the time. Which comment suggests to the nurse that the man may have a serious sleep disorder?
- A. My wife complains because I snore off and on all night.'
- B. I like to nap in the afternoon.'
- C. I wake up early every morning.'
- D. My muscles seem to jerk as I fall asleep.'
Correct Answer: A
Rationale: Snoring may indicate sleep apnea, a serious disorder causing fatigue, unlike napping, early waking, or muscle jerks, which are less concerning.
The nurse is caring for an adult who has kidney stones. Which action is essential for the nurse to take?
- A. Take blood pressure frequently
- B. Keep the client on bed rest
- C. Position the client supine
- D. Strain all urine
Correct Answer: D
Rationale: Straining urine captures kidney stones for analysis, guiding treatment. Blood pressure, bed rest, or positioning are not primary.
A client receiving Gentamycin (garamycin) IVPB has a morning peak level of 12 μg/mL. The nurse should:
- A. Notify the physician because the level is too high.
- B. Administer the medication at the scheduled time.
- C. Request an order to administer the medication IM.
- D. Repeat the level 30 minutes before the next dose.
Correct Answer: A
Rationale: The nurse should notify the physician because the level is too high (therapeutic range for Garamycin is 4-10 μg/mL). Answers B and C are incorrect because they would increase the peak level. Answer D refers to the time for drawing a trough level, making it incorrect.