271 EAQ
A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? 1 Pain subsides as a result of arteriole and venous dilation. 2 Pulse rate increases because the cardiac output has been stimulated. 3 Sublingual area tingles because sensory nerves are being triggered. 4 Capacity for activity improves as a response to increased collateral circulation.
1. Pain subsides as a result of arteriole and venous dilation. Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain. An increased pulse rate does not indicate effectiveness; it is a side effect of nitroglycerin. The tingling indicates that the medication is fresh; relief of pain is the only indicator of effectiveness. Nitroglycerin does not promote the formation of new blood vessels.
A client is admitted to the hospital with a diagnosis of acute salmonellosis. What does the nurse expect the health care provider to prescribe? 1 Cathartics 2 Electrolytes 3 Antidiarrheals 4 Antispasmodics
2. Electrolytes Fluids of dextrose and normal saline and electrolytes are administered to prevent profound dehydration caused by excessive loss of water and electrolytes through diarrheal output. Cathartics are not necessary; salmonellosis is a condition that increases intestinal peristalsis, causing diarrhea. Antidiarrheals are not used when a bacterial infection is diagnosed because slowed peristalsis impedes the excretion of the microorganism. Antispasmodics are not used when bacterial infection is diagnosed because slowed peristalsis decreases excretion of the microorganism.
A client is scheduled to receive intravenous (IV) fluids to be delivered at 80 mL/hr. To adjust the drip rate when administering the IV via gravity, what must the nurse determine? 1 Total volume of fluid in the IV bag 2 Size of the needle or catheter in the vein 3 Drops per milliliter delivered by the infusion set 4 Diameter of the tubing being used to instill the fluid
3 Drops per milliliter delivered by the infusion set Different infusion sets deliver different preset numbers of drops per milliliter. Knowing this is a necessity for calculating the drip rate. Total volume of fluid in the IV bag and size of the needle or catheter in the vein do not determine the drip rate. Diameter of the tubing being used to instill the fluid determines the size of the drop, not the drip rate.
A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. 50% of fluid replacement should be administered in the first 8 hours; then the remaining 50% given over the next 16 hours. What does the nurse calculate the hourly intravenous (IV) fluid to be for the first 8 hours of fluid replacement therapy? Record your answer using a whole number. ___ mL/hr
50% of the total volume to be infused is 3600 mL (7200/2 = 3600). The total time of infusion for this volume is 8 hours. 3600 mL/8 hours = 450 mL/hr.
The client is prescribed potassium iodide solution prior to surgery for a subtotal thyroidectomy. What explanation should the nurse give as to why this medication should be taken? 1 The metabolic rate of the body will increase. 2 It will reduce the risk of hemorrhage during surgery. 3 It will maintain the functioning of the parathyroid glands. 4 The amount of thyroid hormones being secreted will decrease.
2 It will reduce the risk of hemorrhage during surgery Potassium iodide, which aids in decreasing vascularity of the thyroid gland, decreases the risk for hemorrhage. Thyroid hormone antagonists help decrease the body's metabolism. Potassium iodide does not regulate parathyroid function. Thyroid hormone antagonists help decrease the amount of thyroid hormones being secreted.
A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication? 1 Place the pill inside the cheek and let it dissolve. 2 Place the pill under the tongue and let it dissolve. 3 Chew the pill thoroughly and then swallow it. 4 Swallow the pill with a full glass of water.
2 Place the pill under the tongue and let it dissolve. Sublingual medication is placed under the tongue and is quickly absorbed through the mucous membranes into blood. The buccal route requires placing medication between the cheek and gums. Chewing the pill and then swallowing it may be done for oral administration of some large size pills, but not with the sublingual route of administration. Taking the pill with water is required with the PO route of administration of medication, but not with sublingual. In addition, a full glass of water may be an excessive amount of fluid to swallow one pill.
A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon? 1 Eat a snack before going to bed. 2 Measure the blood glucose level between 2 AM and 4 AM. 3 Identify whether morning symptoms are typical for hyperglycemia. 4 Administer the prescribed bedtime insulin immediately before going to bed.
2. Measure the blood glucose level between 2 AM and 4 AM. During the hours of sleep, the Somogyi effect may be caused by a decline in the blood glucose level in response to too much insulin. The resulting hypoglycemia stimulates counterregulatory hormones, which precipitate lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia and ketosis. Treatment involves decreasing the evening insulin. The client should check blood glucose between 2 AM and 4 AM and if the blood glucose is less than 70, the client is having a Somogyi effect. The dawn phenomenon is characterized by the release of counterregulatory hormones in the predawn hours, precipitating hyperglycemia on awakening. Treatment involves an increase in insulin. Eating a snack before going to bed should be done when insulin is taken before sleep, but it will not help to differentiate between the Somogyi effect and the dawn phenomenon. Administering the prescribed bedtime insulin immediately before going to bed depends on the insulin regimen prescribed by the health care provider and will not help to differentiate between the Somogyi effect and the dawn phenomenon. The manifestation (symptoms) of hyperglycemia has no role in differentiating the conditions.
A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy? 1 Bleeding at the infusion site 2 Shortness of breath with crackles 3 Feeling of warmth throughout the body 4 Infiltration at the catheter insertion site
2. Shortness of breath with crackles Hypervolemia may precipitate pulmonary edema, which produces shortness of breath, crackles, cough, apprehension, and frothy sputum. Although bleeding at the infusion site may occur, it is not the most serious complication; an altered respiratory status is the priority. Feeling of warmth throughout the body occurs with the IV administration of dye for diagnostic procedures; it does not occur with IV fluids, such as 0.9% sodium chloride (NaCl) or D5W without an additive. Although infiltration at the catheter insertion site may occur, it is not the most serious complication; an altered respiratory status is the priority.
Carbidopa/levodopa is prescribed for a client with Parkinson disease. What will the nurse teach the client about this medication? 1 "Take this medication between meals." 2 "Blood levels of the drug should be monitored weekly." 3 "It can cause happy feelings followed by feelings of depression." 4 "You may experience dizziness when moving from sitting to standing."
4"You may experience dizziness when moving from sitting to standing." Carbidopa/levodopa is a metabolic precursor of dopamine; it reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension. Carbidopa/levodopa should be administered with food to minimize gastric irritation. Although periodic tests to evaluate hepatic, renal, and cardiovascular status are required for prolonged therapy, whether these tests should be done on a weekly basis has not been established. Carbidopa/levodopa may produce either happiness or depression, but no established pattern of such responses exists.
What does a nurse who is caring for a client experiencing anginal pain expect to observe about the pain? 1 Unchanged by rest 2 Precipitated by light activity 3 Described as a knifelike sharpness 4 Relieved by sublingual nitroglycerin
4. Relieved by sublingual nitroglycerin Relief by sublingual nitroglycerin is a classic reaction because it dilates coronary arteries, which increases oxygen to the myocardium, thus decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness.
What will the nurse include when developing a teaching plan for a client receiving digoxin for left ventricular failure? 1 Sleep flat in bed 2 Follow a low-potassium diet 3 Take the pulse three times a day 4 Rest periodically throughout the day
4. Rest periodically throughout the day Rest decreases demand on the heart and will prevent fatigue. Sleeping with the head slightly elevated facilitates respiration. The client needs potassium. A low-potassium diet when the client is taking digoxin predisposes the client to toxicity and dangerous dysrhythmias. To avoid becoming obsessed with the pulse rate, the client should take the pulse less often; once daily is adequate.
A client with laryngeal cancer is receiving chemotherapy. Which laboratory report is most important for the nurse to monitor when considering the effects of chemotherapy? 1 Platelets 2 Hemoglobin level 3 Red blood cell count 4 White blood cell count
7. White blood cell count Antineoplastic drugs depress bone marrow, which results in leukopenia; the client must be protected from infection, which may cause death. Platelets may decrease rapidly, but complications may be limited by infusions of platelets. Although the hemoglobin level diminishes, a transfusion with packed red blood cells (RBCs) will alleviate the anemia. RBCs diminish slowly and may be replaced with a transfusion of packed red blood cells.
