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The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain.
Which of the following observations is MOST important for the nurse to report to the next shift?
- A. The client indicates the need to use the bathroom.
- B. Blood pressure has decreased from 140/80 to 90/60.
- C. Respiratory rate has increased from 16 to 24.
- D. The client indicates that the chest pain has subsided.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read answer choices for clues. (1) not a side effect of this medication (2) correct-hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome
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The nurse is caring for a client with a history of asthma who is receiving albuterol via nebulizer. Which of the following findings should the nurse report immediately?
- A. Heart rate of 120 bpm.
- B. Respiratory rate of 20 breaths/min.
- C. Oxygen saturation of 95%.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A heart rate of 120 bpm suggests tachycardia, a serious albuterol side effect. Options B, C, and D are normal or expected.
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
- A. I cannot give this medication as it is written. I have no idea of what you mean.
- B. Would you please clarify what you have written so I am sure I am reading it correctly?
- C. I am having difficulty reading your handwriting. It would save me time if you would be more careful.
- D. Please print in the future so I do not have to spend extra time attempting to read your writing.
Correct Answer: B
Rationale: Would you please clarify what you have written so I am sure I am reading it correctly? This is respectful and ensures patient safety.
The nurse is caring for a client who is postoperative day 1 after a nephrectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urine output of 30 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-nephrectomy requiring immediate evaluation. Options B, C, and D are expected or normal: incision pain is typical, urine output 30 mL/hour is adequate for one kidney, and blood pressure 130/80 mmHg is stable.
A man who had a cerebrovascular accident has expressive aphasia. Which approach will help communication the most?
- A. The nurse should write to the client and the client should write back.
- B. The nurse should anticipate the client's needs as much as possible.
- C. The nurse should encourage the client to speak as much as possible.
- D. A family member should stay with the client and express the client's needs to the nurse.
Correct Answer: C
Rationale: Encouraging speech practice aids communication recovery in expressive aphasia, fostering independence. Writing, anticipating needs, or relying on family are less effective.
A client after an electroconvulsive therapy (ECT) treatment.
The nurse should report which observation to the client's physician?
- A. Headache.
- B. Disruption in short- and long-term memory.
- C. Transient confusional state.
- D. Backache.
Correct Answer: D
Rationale: Strategy: You are looking for something unexpected. (1) expected effect (2) expected effect (3) expected effect (4) correct-client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician