Nokea
A 36-year-old client tested positive for the tuberculosis antibody and was placed on isoniazid (INH) four weeks ago. The nurse would be MOST concerned if which of the following was observed?
- A. Fatigue and dark urine.
- B. Malaise and glucosuria.
- C. Proteinuria and lethargy.
- D. Diluted urine and epigastric distress.
Correct Answer: A
Rationale: initial indications of hepatic dysfunction
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A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST?
- A. Remove the scab.
- B. Apply a wet cloth to the lesion.
- C. Notify the child's parents.
- D. Contact the health department.
Correct Answer: C
Rationale: describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician
A client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 cc/h. It is MOST important for the nurse to take which of the following actions?
- A. Massage the client's legs to increase circulation.
- B. Elevate the knee gatch to reduce stress on the suture line.
- C. Apply thigh-high TED hose to promote venous return.
- D. Decrease fluid intake to 1,200 cc to prevent circulatory overload.
Correct Answer: C
Rationale: use of antiembolic hose and/or sequential compression devices decreases venous stasis and reduces risk of thrombus formation
The nurse is teaching a client with a new diagnosis of depression about citalopram (Celexa). Which of the following statements by the client indicates a need for further teaching?
- A. I should report suicidal thoughts to my doctor.
- B. I should take this medication in the morning.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping citalopram when feeling better is incorrect, as depression requires prolonged treatment to prevent relapse. Options A, B, and C are correct: suicidal thoughts require immediate reporting, morning dosing minimizes insomnia, and alcohol increases sedation.
A client is admitted with a fractured right hip. The doctor writes an order for Buck's traction. Which of the following actions, if taken by the nurse, is MOST important?
- A. Turn the client every two hours to the unaffected side.
- B. Maintain the client in a supine position.
- C. Encourage the client to use a bedside commode.
- D. Placing a footboard on the bed.
Correct Answer: A
Rationale: immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side