Nokea
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
- A. Extremities warm to touch.
- B. Improved respiratory status.
- C. Decreased muscle pain with activity.
- D. Participation in self-care measures.
- E. Lungs clear to auscultation.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
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The nurse administering a dose of scopolamine to a preoperative client should monitor the client for which common side effect of the medication?
- A. Dry mouth
- B. Diaphoresis
- C. Excessive urination
- D. Pupillary constriction
Correct Answer: A
Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication.
A client has received an overdose of sympathomimetic agents. The nurse should assess the client for which of the following late signs of an overdose? Select all that apply.
- A. Hypotension.
- B. Bradycardia.
- C. Seizures.
- D. Profound pyrexia.
- E. Hypertension.
Correct Answer: C, D, E
Rationale: Sympathomimetic overdose can cause seizures, profound pyrexia (fever), and hypertension due to excessive stimulation of the sympathetic nervous system.
A client at 37 weeks' gestation is scheduled for a biophysical profile. Which of the following should the nurse instruct the client to do before the test?
- A. Drink 1 to 2 L of fluid.
- B. Take nothing by mouth after midnight before the test.
- C. Plan to remain in the clinic for 4 hours after the test.
- D. Eat a high-fiber meal after the test.
Correct Answer: A
Rationale: Drinking 1-2 L of fluid ensures adequate amniotic fluid volume, which is assessed during a biophysical profile.
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should explain that this medication works by:
- A. Neutralizing gastric acid.
- B. Reducing gastric acid secretion.
- C. Coating the stomach lining.
- D. Increasing gastric motility.
Correct Answer: B
Rationale: Ranitidine, an H2-receptor blocker, reduces gastric acid secretion, helping to heal peptic ulcers.
The nurse cares for a client who is pale and frequently reports fatigue, weakness, and dizziness. Which serum laboratory test result is the nurse's priority for planning care?
- A. Hematocrit 43% (0.43)
- B. Sodium 130 mEq/L (130 mmol/L)
- C. Potassium 4.8 mEq/L (4.8 mmol/L)
- D. Hemoglobin of 7 g/dL (70 mmol/L)
Correct Answer: D
Rationale: The client's hemoglobin level and sodium level are low; however, the nurse uses the hemoglobin results to plan care because the client's clinical indicators are consistent with anemia. The client is pale because the serum hemoglobin is low; thus, the client's tissues are perfused with blood that has a low oxygen-carrying capacity. The client is weak and dizzy because the blood does not carry enough oxygen to meet tissue oxygen demands. The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Although a client who is hyponatremic can also feel weak and dizzy, a hyponatremic client is unlikely to be pale. The hematocrit and the potassium levels are within normal limits.