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Showing all 10 practice questions with expert explanatory rationales.
The physician has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse contacts the physician to discuss the potential for:
Expert Explanatory Rationale
Correct Answer: Increased intraocular pressure
Nitroglycerin can increase intraocular pressure, which is a concern in closed-angle glaucoma, potentially worsening the condition. Hypotension is a common side effect but not specific to glaucoma.
A client with a history of depression is prescribed sertraline (Zoloft). The nurse should teach the client to report which side effect?
Expert Explanatory Rationale
Correct Answer: Suicidal thoughts
Suicidal thoughts are a serious side effect of SSRIs like sertraline, especially in the early weeks, requiring immediate reporting to ensure client safety.
The mother of a child with newly diagnosed Duchenne's muscular dystrophy asks how her child developed the disease. The nurse formulates a response incorporating which of the following statements about its transmission?
Expert Explanatory Rationale
Correct Answer: It is a disorder usually carried by females and transmitted to male children
Duchenne's muscular dystrophy is an X-linked recessive disorder, typically carried by females and transmitted to male children, who are more likely to express the disease.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
Expert Explanatory Rationale
Correct Answer: Continue to assess the neonate.
The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.
The nurse is beginning the shift and is now responsible for the following clients on the postpartum unit and has not yet made rounds on the clients. Additionally, the nurse is responsible for three other clients who are currently listed as stable. The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first?
Expert Explanatory Rationale
Correct Answer: The mother with a 4-hour-old infant with initial blood glucose of 33 mg\dL and now at 15 mg/dL.
The infant with a blood glucose of $15 \mathrm{mg} / \mathrm{dL}$ is critically low, indicating severe hypoglycemia, which requires immediate intervention to prevent neurological damage.
The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long?
Expert Explanatory Rationale
Correct Answer: 2 to 4 weeks
Antidepressants typically take 2 to 4 weeks to achieve full therapeutic effect, as they require time to adjust neurotransmitter levels. Other timeframes are too short or overly prolonged.
The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
Expert Explanatory Rationale
Correct Answer: There is an air leak somewhere in the system.
Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
A client who sustained a fractured leg has learned how to use crutches. The nurse should determine that the client has a need for further teaching if the client makes which statement about using crutches?
Expert Explanatory Rationale
Correct Answer: I will keep the set of crutches my son used as a spare pair.
The client should use only crutches measured for the client. Crutches belonging to another person should not be used unless they have been adjusted to fit the client. Spare tips and crutches fitted to the client should be available if needed. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor.
If crutch tips get wet, the client should dry them with a cloth or paper towel. The tips should be regularly inspected for wear.
The nurse is preparing to assess a client admitted with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom should the nurse expect the client is experiencing?
Expert Explanatory Rationale
Correct Answer: Abrupt onset of pain in the area of the fifth cranial nerve
Trigeminal neuralgia is a chronic syndrome characterized by an abrupt onset of pain. It involves one or more divisions of the trigeminal nerve (cranial nerve V). The remaining options are incorrect.
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
Expert Explanatory Rationale
Correct Answer: Continuous bubbling in the water seal chamber
Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.
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