Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Blood pressure
Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness
Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights
Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status
Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
This question is an excerpt from Nurse Dive's nursing test bank - Med Surg Exam Antelope Valley College Proctored Exam. Take the full exam now
Full Explanation
A. Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
Similar Questions
The nurse is teaching a client how to use nasal spray. What will the nurse include in the teaching plan? (Select all that apply.)
A. Sit up comfortably in the bed.
Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side.
Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril.
Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray.
Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray.
Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.
Full Explanation
A. Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.
The nurse is caring for a client taking fluoxetine for depression. Which assessment findings indicate that the medication is effective? (Select all that apply.)
A. Improved sleep
Improved sleep is correct; an effective antidepressant can help normalize sleep patterns, which is a positive indicator of treatment efficacy.
B. Decreased anxiety
Decreased anxiety is correct; fluoxetine is also effective in treating anxiety symptoms, so a reduction indicates the medication is working.
C. Reduced appetite
Reduced appetite is incorrect; while some individuals may experience appetite changes, a reduced appetite is not an indicator of effectiveness and could indicate a side effect.
D. Weight loss
Weight loss is incorrect; while weight loss can occur, it is not a definitive measure of the effectiveness of fluoxetine and can also signify side effects.
E. Interest in physical activity
Interest in physical activity is correct; an increase in motivation and engagement in activities is a strong indicator of improvement in depressive symptoms.
Full Explanation
A. Improved sleep is correct; an effective antidepressant can help normalize sleep patterns, which is a positive indicator of treatment efficacy.
B. Decreased anxiety is correct; fluoxetine is also effective in treating anxiety symptoms, so a reduction indicates the medication is working.
C. Reduced appetite is incorrect; while some individuals may experience appetite changes, a reduced appetite is not an indicator of effectiveness and could indicate a side effect.
D. Weight loss is incorrect; while weight loss can occur, it is not a definitive measure of the effectiveness of fluoxetine and can also signify side effects.
E. Interest in physical activity is correct; an increase in motivation and engagement in activities is a strong indicator of improvement in depressive symptoms.
A client has been prescribed a tricyclic antidepressant and the nurse recognizes the client's associated risk for anticholinergic effects. What should the nurse teach the client about preventing and managing these adverse effects? (Select all that apply.)
A. Maintain good oral hygiene to minimize dry mouth.
Maintain good oral hygiene to minimize dry mouth is correct; good oral hygiene practices can help alleviate dry mouth, which is a common anticholinergic effect.
B. Void before taking the medication so urinary hesitation is less problematic.
Void before taking the medication so urinary hesitation is less problematic is correct; this strategy can help manage urinary retention, another potential side effect of tricyclic antidepressants.
C. Avoid situations where bruising or lacerations are a possibility.
Avoid situations where bruising or lacerations are a possibility is incorrect; while caution is always advisable, this statement does not directly relate to anticholinergic effects.
D. Eat several small meals daily rather than three larger meals.
Eat several small meals daily rather than three larger meals is correct; smaller meals can help mitigate gastrointestinal side effects and maintain steady blood sugar levels.
E. Use caution in situations where it may be possible to become overheated.
Use caution in situations where it may be possible to become overheated is correct; anticholinergic medications can impair thermoregulation, increasing the risk of heat-related illnesses.
Full Explanation
A. Maintain good oral hygiene to minimize dry mouth is correct; good oral hygiene practices can help alleviate dry mouth, which is a common anticholinergic effect.
B. Void before taking the medication so urinary hesitation is less problematic is correct; this strategy can help manage urinary retention, another potential side effect of tricyclic antidepressants.
C. Avoid situations where bruising or lacerations are a possibility is incorrect; while caution is always advisable, this statement does not directly relate to anticholinergic effects.
D. Eat several small meals daily rather than three larger meals is correct; smaller meals can help mitigate gastrointestinal side effects and maintain steady blood sugar levels.
E. Use caution in situations where it may be possible to become overheated is correct; anticholinergic medications can impair thermoregulation, increasing the risk of heat-related illnesses.