You administered sublingual nitroglycerin (a vasodilator) and oxygen at 3 liters per minute for a client with angina. Which of the following results would help you conclude that these interventions were effective? The client:
1. stops coughing.
2. has clear lung sounds.
3. denies any chest pain.
4. has a flushed face and a slight headache.
ANS: 3
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While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position,
followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.
The nurse would like to start a self-help group for persons who would like to lose weight. Which organization would it be helpful for this nurse to contact?
1. American Nurses Association 2. National League for Nursing 3. National Mental Health Consumers' Self-Help Clearinghouse 4. National Coalition of Self-Help
A nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient's blood pressure is 90/60 mm Hg, and the apical pulse is 108 beats/min. What should be the nurse's first action?
a. Check the dressing for bleeding. b. Notify the registered nurse (RN). c. Document the vital signs. d. Increase the rate of infusion of intraven-ous fluids.
A patient diagnosed with MODS is being mechanically intubated and is unable to eat. Enteral feedings are prescribed along with a proton-pump inhibitor. Which particular intervention is indicated related to this medication?
1. Monitor the serum sodium level. 2. Monitor the uric acid level. 3. Monitor for the development of ventilator-associated pneumonia. 4. Monitor for the development of urinary tract infection.