Nokea
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation causes weak or absent femoral pulses.
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Which of the following actions should the nurse take?
- A. Encourage the client to watch television
- B. Administer a dose of atomoxetine to decrease anxiety
- C. Teach the client how to meditate
- D. Sit with the client to provide a sense of security.
Correct Answer: D
Rationale: Providing a calming presence can help de-escalate panic symptoms.
The nurse should first address the client’s-------followed by the client’s-----
- A. safety
- B. abrasions
- C. hygiene
- D. heart rate
- E. pain
- F. BMI
Correct Answer: E,A
Rationale: Addressing pain and safety prioritizes client needs.
A nurse is assessing a client who is taking haloperidol and is experiencing pseudo parkinsonism. Which of the following findings should the nurse document as a manifestation of pseudo parkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudo parkinsonism is a common side effect of antipsychotic medications like haloperidol. A shuffling gait is a characteristic manifestation, which includes slow, shuffling, and stiff movements resembling those seen in Parkinson's disease. This occurs due to the blockade of dopamine receptors in the brain.
Choice A, serpentine limb movement, is not a typical manifestation of pseudo parkinsonism. Choice C, nonreactive pupils, is more indicative of a possible neurological issue. Choice D, smacking lips, is a manifestation of tardive dyskinesia, not pseudo parkinsonism.
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
- B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8
- D. A client who received a Mantoux test 48 hr ago and has an induration
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care as the INR is subtherapeutic, increasing the risk of clot formation. A therapeutic INR for clients on warfarin is typically between 2-3. Options A, B, and D do not require immediate follow-up care. A potassium level of 3.6 mEq/L is within the normal range. Sodium phosphate for a colonoscopy preparation is appropriate. An induration after a Mantoux test is an expected finding.
Which of the following laboratory findings should the nurse expect following the transfusion?
- A. Increased platelets
- B. Increased Hct
- C. Decreased Hgb
- D. Decreased WBC count
Correct Answer: B
Rationale: The correct answer is B: Increased Hct. Following a transfusion, the nurse should expect an increase in hematocrit (Hct) levels due to the addition of packed red blood cells. This will result in an increase in the concentration of red blood cells in the blood, leading to a higher Hct value. The other choices are incorrect as: A) Increased platelets are not typically affected by a red blood cell transfusion, C) Decreased Hgb would not be expected as the purpose of the transfusion is to increase hemoglobin levels, and D) Decreased WBC count is unrelated to a red blood cell transfusion.