Nokea
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
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On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
- A. Decrease the rate of the intravenous infusion.
- B. Change the type of intravenous fluid being administered.
- C. Change the urinary catheter.
- D. Increase the rate of the intravenous infusion.
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.
The nurse is teaching a client with a new diagnosis of asthma about using an albuterol inhaler. Which of the following statements by the client indicates a need for further teaching?
- A. I should shake the inhaler before using it.
- B. I should hold my breath for 10 seconds after inhaling.
- C. I should use the inhaler every 4 hours even if I feel fine.
- D. I should rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Using albuterol every 4 hours without symptoms is incorrect, as it is a rescue inhaler for acute symptoms, not maintenance. Options A, B, and D are correct: shaking ensures proper dose, holding breath maximizes absorption, and rinsing prevents oral thrush (though more relevant for steroids).
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Leg swelling on the operative side.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-hip replacement requiring immediate evaluation. Options B, C, and D are expected or less concerning: incision pain and leg swelling are normal, and urine output 40 mL/hour is adequate.
A diabetic client is taking Lantus insulin for regulation of his blood glucose levels. The nurse should know that this insulin will most likely be administered:
- A. Prior to each meal
- B. At night
- C. Midday
- D. Prior to the evening meal
Correct Answer: B
Rationale: Lantus is a long-acting insulin typically administered at night to provide basal coverage. Options A, C, and D are incorrect for its dosing schedule.