Nokea
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:
- A. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect.
- B. Nitroglycerin should be avoided if the client is experiencing this serious side effect.
- C. Taking the nitroglycerin with a few glasses of water will reduce the problem.
- D. The client should lie in a supine position to alleviate the headache.
Correct Answer: A
Rationale: Headache is a common side effect of nitroglycerin due to vasodilation. Acetaminophen or ibuprofen can safely relieve it without discontinuing the medication.
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The surgeon orders cefazolin (Ancef) 1 g to be given I.V. at 7:30 a.m. when the client's surgery is scheduled at 8:00 a.m. What is the primary reason to start the antibiotic exactly at 7:30 a.m.?
- A. Legally the medication has to be given at the ordered time.
- B. The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.
- C. The postoperative dose of Ancef needs to be started exactly 8 hours after the preoperative dose of Ancef.
- D. The peak and titer levels are needed for antibiotic therapy.
Correct Answer: B
Rationale: Administering cefazolin 30 to 60 minutes before incision ensures optimal tissue levels to prevent surgical site infections. Timing is critical for prophylactic efficacy, not legal requirements or postoperative dosing schedules.
Amoxicillin trihydrate (Amoxil) 300 mg P.O. has been prescribed for a client with an oral infection. The medication is available in a liquid suspension that is available as 250 mg/5 mL. How many milliliters would the nurse administer?
Correct Answer: 6 mL
Rationale: To calculate the dose: (300 mg / 250 mg) × 5 mL = 6 mL. The nurse should administer 6 milliliters of the amoxicillin suspension to deliver the prescribed 300 mg dose.
A client's job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following?
- A. Muscle aches.
- B. Thirst.
- C. Lethargy.
- D. Orthostatic hypotension.
Correct Answer: D
Rationale: Frequent bending and crouching in a warm, dry environment increases the risk of orthostatic hypotension due to dehydration and positional changes.
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
- A. Empty and measure indwelling urinary catheter collection bags.
- B. Reposition clients for pain relief.
- C. Teach clients the proper use of the incentive spirometer.
- D. Tell the nurse if clients report they are having pain.
- E. Assess I.V. insertion site for redness.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (A), reposition clients (B), and report pain (D). Teaching (C) and assessing IV sites (E) require nursing judgment and are outside their scope.
Which of the following client situations would require the most intensive nursing interventions for immobility?
- A. A 38-year-old woman receiving internal radiation therapy for cervical cancer.
- B. A 7-year-old boy with leukemia hospitalized for induction of high-dose chemotherapy.
- C. A 75-year-old man with metastatic prostate cancer hospitalized for a pathologic fracture of the femur.
- D. A 6-month-old undergoing surgery for placement of a central venous catheter.
Correct Answer: C
Rationale: A 75-year-old man with a pathologic femur fracture requires the most intensive nursing interventions for immobility due to pain, risk of further injury, and need for mobility aids and rehabilitation.