Nokea
A client develops severe, crushing chest pain radiating to the left shoulder and arm.
Which of the following PRN medications should the nurse administer?
- A. Diazepam (Valium) PO.
- B. Meperidine (Demerol) IM.
- C. Morphine sulfate IV.
- D. Nitroglycerine (Nitrostat) SL.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not an appropriate medication in this situation; antianxiety medication (2) Demerol is less commonly used because it may induce vomiting and initiate a vagal response (3) correct-morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload pressures (4) although a client at home may have taken NTG SL, the nurse would administer it IV to reduce pain and decrease overload
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A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening
- B. Perform tests for sexually transmitted diseases
- C. Discuss her high risk for cervical cancer
- D. Refer the client to a family planning clinic
Correct Answer: A
Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step to ensure early treatment if positive.
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
- A. Impaired adjustment
- B. Impaired home maintenance
- C. Ineffective family therapeutic regimen management
- D. Noncompliance
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
- A. Measure head circumference
- B. Place in airborne isolation
- C. Provide passive range of motion
- D. Provide an over-the-crib protective top
Correct Answer: A
Rationale: Measure head circumference. This monitors for complications like hydrocephalus in meningitis.
The nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments?
- A. Rely on child's self-report
- B. Use a peak-flow meter
- C. Note skin color changes
- D. Monitor pulse rate
Correct Answer: B
Rationale: The peak flow meter, if used correctly, shows effectiveness of inhalants.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) from furosemide increases arrhythmia risk in heart failure. Options B, C, and D are normal.