Nokea
Which of the following situations warrants a measurement for orthostatic hypotension?
- A. A 36-year-old male with a spinal injury
- B. An 86-year-old female with significantly altered mental status
- C. A 58-year-old female with near-syncope
- D. A 41-year-old male with acute deep vein thrombosis
Correct Answer: C
Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.
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Which of the following interventions is necessary before insertion of an arterial line into the radial artery?
- A. Ensure that the client does not need surgery
- B. Assess the client's grip strength
- C. Perform an Allen test
- D. Check a serum potassium level
Correct Answer: C
Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line.
Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure. Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation. Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
- A. Kussmaul respirations
- B. Cheyne-Stokes respirations
- C. Biot's respirations
- D. Cluster breathing
Correct Answer: A
Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.
The nurse provides instructions to the client taking clorazepate for the management of an anxiety disorder. What information related to this medication should the nurse provide to the client?
- A. Dizziness is a side effect.
- B. Smoking increases the effectiveness of the medication.
- C. If drowsiness occurs, call the primary health care provider.
- D. If gastrointestinal disturbances occur, discontinue the medication.
Correct Answer: A
Rationale: Dizziness is a common side effect of clorazepate, and clients should be instructed to change positions slowly to manage it. Smoking reduces the medication's effectiveness, drowsiness is expected and does not require contacting the provider, and gastrointestinal disturbances should be managed by taking the medication with food, not discontinuing it.
A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions?
- A. I will report a fever or sore throat to my doctor.
- B. Some joint pain is expected and is nothing to worry about.
- C. I must brush my teeth frequently to avoid damage to my gums.
- D. My urine may turn red in color, but this is nothing to be concerned about.
Correct Answer: A
Rationale: Carbamazepine is an anticonvulsant medication and is also used to alleviate the pain associated with trigeminal neuralgia. Agranulocytosis is an adverse effect of carbamazepine, and it places the client at risk for infection. If the client develops a fever or a sore throat, the primary health care provider should be notified. Unusual bruising and bleeding are also adverse effects of the medication, and they need to be reported to the primary health care provider if they occur.
The nurse is instructing a pregnant client regarding measures to prevent a recurrent episode of preterm labor. Which statement by the client indicates the need for further teaching?
- A. I will report any feeling of pelvic pressure.
- B. I will not engage in sexual intercourse at this time.
- C. I will adhere to the limitations in activity and stay off my feet.
- D. I will limit my fluid intake to three 8-ounce glasses of fluid per day.
Correct Answer: D
Rationale: Risks for preterm labor include dehydration. A client should not restrict fluids (except for those containing alcohol and caffeine). A sign of preterm labor may be pelvic pressure without the perception of a contraction. Mechanical stimulation of the cervix during intercourse can stimulate contractions. A decrease in activity and bed rest are often prescribed in an attempt to decrease pressure on the cervix and to increase uterine blood flow.