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Questions 158

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Question 1 of 5

A client with advanced Alzheimer’s disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?

Correct Answer: B

Rationale: Haloperidol, an antipsychotic, commonly causes extrapyramidal side effects like tremors. Cough (
A), diarrhea (
C), and pitting edema (
D) are not typical side effects of haloperidol.

Question 2 of 5

A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?

Correct Answer: A

Rationale: These are tetanic in nature and can cause rupture of the uterus. The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. Beat-to-beat variability is a normal finding and demonstrates fetal well-being. The FHR may decrease at the beginning of a contraction owing to head compression.

Question 3 of 5

A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

Correct Answer: C

Rationale: The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.

Question 4 of 5

The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?

Correct Answer: D

Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.

Question 5 of 5

An elderly client is diagnosed with interstitial cystitis. Which finding differentiates interstitial cystitis from other forms of cystitis?

Correct Answer: B

Rationale: Interstitial cystitis is characterized by chronic pelvic pain and urinary symptoms without bacterial infection, so the urine is typically free of bacteria, unlike bacterial cystitis.

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