Q&A Random Selection # 2 Rationale

1 C: Pulse rate of 48 BPM. One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac
arrest (this drug should never be administered without continuous EKG monitoring).

2 B: The best time for a breast self exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and
tender due to hormone elevation.

3 C: Anticholinergics. In contrast to anorexics, individuals with bulimia are troubled by their behavioral characteristics and
become depressed. The person feels compelled to binge, purge and fast. Feeling helpless to stop the behavior, feelings of self
disgust occur.

4 A: Evaluating SaO2 levels frequently. The best method to evaluate a client''s oxygenation is to evaluate the SaO 2. This is just as
effective as an arterial blood gas reading to evaluate oxygenation status, and is less traumatic and expensive.

5 B: It can occur in clients taking antipsychotic drugs longer than 2 years. Tardive dyskinesia is a extrapyramidal side effect that
appears after prolonged treatment with antipsychotic medication. Early symptoms of tardive dyskinesia are fasciculations of the
tongue or constant smacking of the lips.

6 D: Serum potassium. Potassium is lost in diabetic ketoacidosis during rehydration and insulin administration. Review of this
lab finding suggests the nurse has knowledge of this problem.

7 A: "I know I must avoid crowds." There are no specific reasons for the client on Coumadin to avoid crowds. General
instructions for any cardiac surgical client include limiting exposure to infection.

8 B: Reporting vomiting or diarrhea. If dehydration results from vomiting, diarrhea or excessive perspiration, tolerance to the
drug may be altered and symptoms may return.

9 A: Serum albumin 2.5 g/dl. Serum albumin level is low (normal 3.0 – 5.0 g/dl in elders), indicating nutritional counseling to
increase dietary protein is needed. Socioeconomic factors may need to be addressed to help the client comply with the
recommendation.

10 D: Turn her to her left side. The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is
flat on her back causing supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the
woman to the side reduces this pressure and relieves postural hypotension.

11 C: NPO then glucose and electrolyte solutions. Post-operatively, the initial feedings are clear liquids in small quantities to
provide calories and electrolytes.

12 B: Vomiting, diarrhea and lethargy. These are early signs of lithium toxicity.

13 A: Provide small feedings every 3 hours. Infants with congenital heart defects are at increased risk for developing congestive
heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the
same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather
than the usual 4 hour schedule.

14 B: Sodium. Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase
in the presence of conditions that cause sodium loss.

15 C: administer oxygen therapy. Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen
is the most critical initial intervention. The other interventions are secondary to oxygen therapy.

16 C: Variable decelerations. When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart rate
patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.

17 D: This type of identification band easily tracks the client''s movements and ensures safety while the client wanders on the
unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
18 D: Red wine, fava beans, aged cheese. Red wine and cheese contain tyramine (as do chicken liver and ripe bananas) and so
are contraindicated when taking MAOIs. Fava beans contain other vasopressors that can interact with MAOIs also causing
malignant hypertension.

19 A: Family understanding of client needs. Functional communication patterns between family members are fundamental to
meeting the needs of the client and family.

20 B: when the client’s mood improves with an increase in energy level. Suicide potential is often increased when there is an
improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.

21 D: "I feel pressure in the middle of my chest, like an elephant is sitting on my chest." This is a classic description of chest
pain in men caused by myocardial ischemia. Women experience vague feelings of fatigue and back and jaw pain.

22 C: "I will stop taking the medication for 1 week every month." Emphatically warn against discontinuing steroid dosage
abruptly because that may produce a fatal adrenal crisis.

23 D: interview the client alone to determine the origin of the injuries. It would be wrong to assume domestic violence without
further assessment. Separate the suspected victim from the partner until battering has been ruled out.

24 C: Assist the client to breathe into a paper bag. Side effects of aspirin toxicity include hyperventilation, which can result in
respiratory alkalosis in the initial stages. Breathing into a paper bag will prevent further reduction in PaCO2.

25 A: Link the caregiver with a support group. Assisting caregivers to locate and join support groups is most helpful. Families
share feelings and learn about services such as respite care. Health education is also available through local and national
Alzheimer''s chapters.

26 C: put the client in knee-chest position. Immediate action is needed to relieve pressure on the cord, which puts the fetus at
risk due to hypoxia. The Trendelenburg position accomplishes this. The exposed cord is covered with saline soaked gauze, not
reinserted. The fetal heart rate also should be checked, and the provider called. A prolapsed umbilical cord is a medical
emergency.

27 B: taking the medication at specified times. A regular interval between doses should be maintained since oral hypoglycemic
stimulate the islets of Langerhans to produce insulin.

28 D: Assess the client''s knowledge about his health problems. The nursing process is continuous and cyclical in nature. When a
client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and
implementing nursing interventions.

29 B: decreased gastrointestinal motility. Together with shrinkage of the gastric mucosa, and changes in the levels of
hydrochloric acid, this will decrease absorption of medications and interfere with their actions.

30 D: "I can hear your concern and that your confusion is upsetting to you." Communicating caring and empathy with the
acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short term effects would be
discussed.

31 A: Bluish coloration of the cervix and vaginal walls. Chadwick''s sign is a bluish-purple coloration of the cervix and vaginal
walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.

32 D: Developmental level. While each of the factors affect communication, the nurse recognizes that developmental differences
have implications for processing and understanding information. Consequently, a child’s developmental level must be considered
when selecting communication approaches.

33 C: cover the wound with sterile saline dressing. When evisceration occurs, the wound should first be quickly covered by
sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.

34 D: Blood pressure. The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client''s
blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.
35 A: Wine, beer, cheese, liver and chocolate. These foods are tyramine rich and ingestion of these foods while taking
monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.

36 D: criss-crossing leg movement. Cerebral palsy is a neuromuscular impairment resulting in muscular and reflexive
hypertonicity and the criss-crossing, or scissoring leg movements.

37 D: Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications
should be followed up immediately.

38 B: HCG. Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is
about 98%, but the test does not conclusively confirm pregnancy.

39 B: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed
determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are
notoriously inaccurate.

40 D: lung sounds. Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction
rub, highly suggestive of a pulmonary embolism.