Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is reviewing the client's medical record.
The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved?
Select all that apply.
A. Pain level
The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B. Respiratory rate
The client’s respiratory rate decreased from 24/min to 22/min.
C. Heart rate
The client’s heart rate decreased from 120/min to 100/min.
D. Oxygenation saturation
Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E. Blood pressure
The blood pressure decreased from 176/82 to 110/62.
F. Echocardiogram results
Only one echocardiogram result showing myocardial infarction was provided.
G. Urinary output
Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Med Surg 2023 Proctored Exam. Take the full exam now
Full Explanation
A) The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B) The client’s respiratory rate decreased from 24/min to 22/min.
C) The client’s heart rate decreased from 120/min to 100/min.
D) Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E) The blood pressure decreased from 176/82 to 110/62.
F) Only one echocardiogram result showing myocardial infarction was provided.
G) Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.
Similar Questions
A nurse is reviewing the client’s medical record
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Potential Prescription: Anticipated Nonessential Contraindicated
A. Metoprolol 15 mg IV bolus
B. Oxygen at 2 L/min via nasal cannula
C. Draw electrolytes along with Hgb and Hct
D. Morphine 6 mg IV bolus every 3 hr as needed for pain
E. Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses
F. Obtain daily weight
G. Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate drops below 60
Full Explanation
A) Metoprolol is a beta-blocker that can help reduce heart rate and blood pressure, which is beneficial in cases of chest pain and irregular tachycardia.
B) Oxygen at 2 L/min via nasal cannula is anticipated because the client's oxygen saturation is below normal, indicating they may benefit from supplemental oxygen.
C) Drawing electrolytes along with Hgb and Hct is anticipated as it is important to monitor these levels due to the client's symptoms and history of hypertension and diabetes.
D) Morphine is anticipated because the client reports pain, and morphine can provide pain relief and reduce the workload on the heart.
E) Nitroglycerin is a standard treatment for chest pain due to its vasodilating effects, which can improve blood flow to the heart.
F) Obtaining daily weight is nonessential at this moment because it does not directly address the acute symptoms the client is experiencing.
G) Atropine is contraindicated as the client's heart rate is tachycardic, not bradycardic, and atropine is used to increase heart rate.
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication?
A. Beef stew
Beef stew do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
B. Orange juice
Orange juice do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
C. Kale
Warfarin's effectiveness can be influenced by vitamin K, which is found in high amounts in kale and other green leafy vegetables. Consistent intake of vitamin K is crucial as fluctuations can affect the International Normalized Ratio (INR), a measure of blood clotting.
D. Yogurt
Yogurt do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
Full Explanation
A) Beef stew do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
B) Orange juice do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
C) Warfarin's effectiveness can be influenced by vitamin K, which is found in high amounts in kale and other green leafy vegetables. Consistent intake of vitamin K is crucial as fluctuations can affect the International Normalized Ratio (INR), a measure of blood clotting.
D) Yogurt do not contain significant amounts of vitamin K and thus have a lesser impact on INR levels.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)
A. Infuse 0.99% sodium chloride if the solution is not available.
Infusing 0.9% sodium chloride is incorrect as it's not appropriate for TPN administration.
B. Obtain the client's weight daily.
Obtaining the client's weight daily helps to monitor nutritional status and adjust TPN accordingly.
C. Monitor serum blood glucose during infusion.
Monitoring serum blood glucose is essential due to the high glucose content in TPN, which can lead to hyperglycemia.
D. Verify the solution with another RN prior to infusion.
Verifying the solution with another RN prior to infusion is a safety measure to ensure the correct solution and dosage.
E. Increase the rate of infusion if administration is delayed.
Increasing the rate of infusion if administration is delayed may lead to complications and is not appropriate without medical orders.
Full Explanation
A) Infusing 0.9% sodium chloride is incorrect as it's not appropriate for TPN administration.
B) Obtaining the client's weight daily helps to monitor nutritional status and adjust TPN accordingly.
C) Monitoring serum blood glucose is essential due to the high glucose content in TPN, which can lead to hyperglycemia.
D) Verifying the solution with another RN prior to infusion is a safety measure to ensure the correct solution and dosage.
E) Increasing the rate of infusion if administration is delayed may lead to complications and is not appropriate without medical orders.