Nokea
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect
- B. Most antipsychotic drugs cause elevated blood pressure
- C. This provides information on the amount of sodium allowed in the diet
- D. It will indicate the need to institute antiparkinsonian drugs
Correct Answer: A
Rationale: Orthostatic hypotension is a common side effect. Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after receiving medication. They should be advised to get up slowly, especially from a supine position.
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After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
Which of these food choices, if selected by a client with diarrhea, would indicate the need for further teaching about dietary management?
- A. orange juice
- B. tuna
- C. eggs
- D. macaroni
Correct Answer: A
Rationale: Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.
The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which finding would call for immediate action by the nurse?
- A. Breath sounds can be heard bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88 BPM
- D. Client is unable to speak
Correct Answer: C
Rationale: Pulse oximetry of 88 BPM. Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked, along with the ventilator settings.
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?
- A. Have him drink several glasses of water
- B. Perform Crede's method on the bladder from the bottom to the top
- C. Assist him to stand by the side of the bed to void
- D. Wait 2 hours and have him try to void again
Correct Answer: C
Rationale: When a male is not able to use a urinal unassisted, the client should stand by the side of the bed to void. This is the most desirable position for normal voiding for male clients. Also, given his age, he most likely has some degree of prostate enlargement which may interfere with voiding.
Which of these statements from clients who call the community health clinic would suggest the need for a same-day appointment to be seen by the health care provider?
- A. I started my period and now my urine has turned bright red'
- B. I am a diabetic and today I have been going to the bathroom every hour'
- C. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom'
- D. I went to the bathroom and my urine looked very red and it didn't hurt when I went'
Correct Answer: D
Rationale: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated with bladder cancer. The other complaints can be handled over the phone.