A client diagnosed with hypertension has been prescribed a c...

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.

A. Apply patch to the upper arm or chest
B. Fold used patches in half with sticky sides together before discarding
C. Remove patch if dizziness occurs when getting up
D. Rotate sites each time a new patch is applied
E. Shave hair before applying patch

Correct Answer: A, B, D

Rationale: Applying to upper arm/chest (A), folding patches (B), and rotating sites (D) ensure safe use. Removing for dizziness (C) requires medical consultation, and shaving (E) can irritate skin.

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An adult who has newly diagnosed angina has been prescribed sublingual nitroglycerin. What should be included in the nurse's teaching about the medication? Select all that apply.

A. Put the tablets under your tongue and let them dissolve.
B. Keep the tablets in a dark glass container.
C. You can take one tablet, and if you still have pain, you can take another tablet in 10 minutes.
D. Be sure to take nitroglycerin while you are standing up.
E. You may get a headache shortly after you take the medication,
F. If your tongue tingles spit out the tablet.

Correct Answer: A,B,E

Rationale: Sublingual nitroglycerin is dissolved under the tongue, stored in dark glass to maintain potency, and may cause headaches as a side effect.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?

A. Contraction duration of 95 seconds
B. Contraction frequency of every 3 minutes
C. Contraction intensity of 45 mm Hg
D. Uterine resting tone of 10 mm Hg

Correct Answer: A

Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time?

A. Check for a history of bipolar disease
B. Determine if restraints can now be removed
C. Monitor for ECG changes
D. Obtain blood for the current blood alcohol level

Correct Answer: B

Rationale: The client is now sleeping, suggesting reduced agitation. Determining if restraints can be removed (B) is the priority to minimize harm and promote safety. Bipolar history (A), ECG changes (C), and blood alcohol level (D) are important but less urgent.

Diagnosis-related groups (DRGs) provide data to

A. Identify clients who have specific medical diagnoses
B. Identify findings related to a medical diagnosis
C. Determine reimbursement for a medical diagnosis
D. Implement nursing care based on case management protocol

Correct Answer: C

Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.

The nurse is reinforcing home care instructions to a client newly diagnosed with osteomalacia. Which of the following client statements indicate proper understanding of teaching? Select all that apply.

A. I will avoid foods high in calcium and phosphorus.'
B. I will avoid going outside on sunny days.'
C. I will eat foods that are fortified with vitamin D.'
D. I will engage in physical activity to increase bone strength.'
E. I will use a cane to help me get around better.'

Correct Answer: C, D

Rationale: Vitamin D-rich foods (C) and physical activity (D) improve bone health in osteomalacia. Avoiding calcium/phosphorus (A), sunlight (B), or using a cane (E) are incorrect or unnecessary.