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A nurse is reinforcing teaching with a client who has a new prescription for loratadine. Which of the following statements should the nurse include?
- A. You should take this medication at bedtime if it causes drowsiness.
- B. You might notice an increase in your appetite.
- C. This medication might cause your skin to turn yellow.
- D. You should stop taking this medication if your symptoms improve.
Correct Answer: A
Rationale: Loratadine may cause mild drowsiness, so bedtime dosing is an option if needed. Appetite and skin color aren't affected, and stopping depends on symptom duration.
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A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?
- A. My child still wets the bed at least two times per week.
- B. I have noticed that my child is withdrawn since we switched day care providers.
- C. I have a difficult time getting my child to eat green vegetables.
- D. My child continually asks me the same questions.
Correct Answer: B
Rationale: Withdrawal after a daycare change suggests emotional distress, a priority over bedwetting, picky eating, or repetitive questions, which are less urgent.
A nurse is assisting with the care of a client who is postoperative following a mastectomy. Which of the following actions should the nurse take?
- A. Encourage the client to perform arm exercises on the affected side.
- B. Keep the client's affected arm in a dependent position.
- C. Monitor the client for signs of infection every 8 hr.
- D. Instruct the client to avoid using a sling on the affected arm.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and stiffness post-mastectomy. Elevation, frequent infection checks, and sling use are standard.
A nurse is caring for a client who has a new prescription for clonazepam. Which of the following actions should the nurse take?
- A. Instruct the client to take the medication daily regardless of need.
- B. Monitor the client for signs of drowsiness.
- C. Administer the medication with a high-fat meal.
- D. Check the client's respiratory rate prior to administration.
Correct Answer: B
Rationale: Clonazepam causes drowsiness, requiring monitoring. It's as prescribed (not always daily), taken without regard to meals, and respiratory checks aren't primary.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
- A. Support the client's decision to stop the treatment.
- B. Tell the client she should discuss this decision with her family.
- C. Ask the facility chaplain to visit the client.
- D. Discuss alternative treatment methods with the client.
Correct Answer: A
Rationale: The nurse must respect the client's autonomy to refuse treatment, supporting their decision and providing end-of-life care resources. Suggesting family discussion, chaplain visits, or alternatives oversteps unless requested by the client.
A nurse is caring for a client who has a new prescription for albuterol via nebulizer. Which of the following actions should the nurse take?
- A. Instruct the client to take shallow breaths during the treatment.
- B. Monitor the client for signs of tachycardia.
- C. Administer the medication every 2 hr.
- D. Check the client's oxygen saturation prior to administration.
Correct Answer: B
Rationale: Albuterol can cause tachycardia, a side effect to monitor. Deep breaths are needed, dosing is typically 4-6 hr, and O2 sat is checked as needed.