Nokea
The unlicensed assistive personnel (UAP) reported an intake of 1,000 mL and a urinary output of 1,500 mL for a client who received a thiazide diuretic this morning. Which nursing task could the nurse delegate to the nursing assistant?
- A. Instruct the UAP to restrict the client's fluid intake.
- B. Request the UAP to insert a Foley catheter with an urometer.
- C. Tell the UAP urinary outputs are no longer needed.
- D. Ask the UAP to document fluids on the bedside I & O record.
Correct Answer: D
Rationale: Documenting I&O is within UAP scope; fluid restriction, catheter insertion, or discontinuing monitoring require nursing judgment.
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The client with coronary artery disease is prescribed atorvastatin (Lipitor) to help decrease the client's cholesterol level. Which intervention should the nurse discuss with the client concerning this medication?
- A. The client should eat a low-cholesterol, low-fat diet.
- B. The client should take this medication with each meal.
- C. The client should take this medication in the evening.
- D. The client should monitor daily cholesterol levels.
Correct Answer: C
Rationale: Atorvastatin is most effective at night when cholesterol synthesis peaks, per pharmacodynamics. Diet is supportive, meals are irrelevant, and daily monitoring is impractical.
An adult client has pulmonary tuberculosis. He is receiving INH 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What advice does the nurse expect will be given to this client?
- A. Take pyridoxine daily.
- B. Expect red-colored urine and feces.
- C. Stop the medications when your cough is gone.
- D. Take streptomycin by mouth instead of by injection.
Correct Answer: B
Rationale: Streptomycin’s ototoxicity may require discontinuation, not pyridoxine (used for INH). Red urine/feces is expected with rifampin, not listed here, but monitoring is key.
A 19-year-old woman has just started taking birth control pills. She calls the clinic nurse to say that her breasts are tender and she is nauseous. The nurse's response is based on which understanding?
- A. These are serious side effects.
- B. These effects usually decrease after three to six cycles.
- C. Taking the pill in the morning reduces its side effects.
- D. Taking the pills every other day reduces its side effects.
Correct Answer: B
Rationale: Breast tenderness and nausea are common initial side effects of oral contraceptives, typically resolving after a few cycles.
The nurse is evaluating the client's home medications and notes the client with angina is taking an antidepressant. Which intervention should the nurse implement because the client is taking this medication?
- A. Ask the client if there is a plan for suicide.
- B. Assess the client's depression on a 1-to-10 scale.
- C. Explain this medication cannot be taken because of the angina.
- D. Request a referral to the hospital psychologist.
Correct Answer: A
Rationale: Antidepressants in angina patients raise suicide risk concerns; assessing for a plan is the priority to ensure safety.
The client diagnosed with status asthmaticus is prescribed intravenous aminophylline, a bronchodilator. Which assessment data would warrant immediate intervention?
- A. The theophylline level is 12 mcg/mL.
- B. The client has expiratory wheezing.
- C. The client complains of muscle twitching.
- D. The client is refusing to eat the meal.
Correct Answer: C
Rationale: Muscle twitching indicates theophylline toxicity, requiring immediate intervention. Normal levels (10–20 mcg/mL), wheezing, or meal refusal are expected or less urgent.