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Questions 148

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Question 1 of 5

The physician has prescribed imipramine (ToFranil) for a client with depression. The nurse should continue to monitor the client's affect because the maximal effects of tricyclic antidepressant medication do not occur for:

Correct Answer: C

Rationale: Tricyclic antidepressants like imipramine take 2-4 weeks to reach maximal therapeutic effect, requiring ongoing monitoring of the client's mood.

Question 2 of 5

The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?

Correct Answer: A

Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.

Question 3 of 5

The nurse should carefully monitor the client for which common dysrhythmia that can occur during suctioning?

Correct Answer: A

Rationale: Suctioning can stimulate the vagus nerve, leading to bradycardia due to parasympathetic activation, especially in clients with tracheostomies or endotracheal tubes.

Question 4 of 5

The nurse finds a client smoking marijuana in the hospital and tells her that no smoking or use of drugs is allowed in the facility. The client responds by shouting, 'What business is it of yours? Leave me alone!' Which of the following initial responses is the best for the nurse to use to defuse the situation?

Correct Answer: D

Rationale: A calm, polite request to stop (
D) de-escalates the situation while reinforcing the rule. Other responses (A, B,
C) are confrontational and likely to escalate the client's agitation.

Question 5 of 5

A client's blood pressure is 132/84. What is the mean arterial pressure?

Correct Answer: C

Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg. Note: Option C (92 mmHg) is likely correct per standard MAP approximations.

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