The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Apical heart rate.

Pulse pressure.

Level of consciousness.

Blood pressure.

Answer and Explanation

The Correct Answer is D

Choice A reason: The apical heart rate is important for other assessments but does not directly assess for orthostatic hypotension.

Choice B reason: Pulse pressure is not specifically related to orthostatic hypotension assessment.

Choice C reason: Level of consciousness can be affected by orthostatic hypotension but is not the primary assessment.

Choice D reason: Blood pressure should be measured in both lying and standing positions to assess for orthostatic hypotension.

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Correct Answer is C

Explanation

Choice A reason: Ear pain and fever are not specific symptoms of mononucleosis and may indicate other infections such as otitis media.

Choice B reason: Elevated WBC (white blood cell) count and sedimentation rate can be seen in many infections and inflammatory conditions, but they are not specifically diagnostic of mononucleosis.

Choice C reason: Mononucleosis, often caused by the Epstein-Barr virus (EBV), typically presents with a positive EBV test and malaise (general feeling of discomfort or illness). Other common symptoms include fever, sore throat, swollen lymph nodes, and fatigue.

Choice D reason: Increased BUN (blood urea nitrogen) and serum creatinine levels are indicators of kidney function and are not typically associated with mononucleosis.

A. Twin siblings admitted with scarlet fever that is complicated with pneumonia. B. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB). C. An older client with scabies who is admitted from an extended care facility. D. A female adolescent admitted with multiple genital Herpes simplex II lesions.

Correct Answer is B

Explanation

Choice A reason: Scarlet fever and pneumonia require droplet precautions, not airborne.

Choice B reason: A positive Mantoux test and positive sputum cultures for AFB indicate tuberculosis, which requires airborne precautions and a negative airflow room.

Choice C reason: Scabies requires contact precautions, not airborne.

Choice D reason: Genital Herpes simplex II requires standard precautions, not airborne.

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The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Nursing Test Bank

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