Nokea
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? 'Take Fosamax
- A. on an empty stomach.'
- B. after meals.'
- C. with calcium.'
- D. with milk 2 hours after meals.'
Correct Answer: A
Rationale: Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.
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The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
- A. My daughter has almost doubled her birth weight.
- B. When I walk in the room my child smiles at me.
- C. When she is around her grandpa, my child cries.
- D. My daughter can't quite say Mama yet.
Correct Answer: A
Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 90 bpm.
- C. Facial flushing and itching.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Report any eye pain or vision changes.
- C. Stop the medication if symptoms improve.
- D. Avoid rinsing the mouth after use.
Correct Answer: B
Rationale: Eye pain or vision changes may indicate glaucoma, a serious tiotropium side effect. Options A, C, and D are incorrect.
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
- A. Maintain the client in a supine position.
- B. Notify the client's next-of-kin.
- C. Prepare the client for emergency surgery.
- D. Remove the nasogastric tube.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done