Nokea
A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
- A. Aspirin
- B. Multivitamins
- C. Omega 3 fish oils
- D. Acetaminophen
Correct Answer: A
Rationale: Aspirin can increase methotrexate toxicity by reducing its renal excretion, leading to potentially severe side effects.
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The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
- A. To lower the blood glucose level
- B. To lower the uric acid level
- C. To lower the ammonia level
- D. To lower the creatinine level
Correct Answer: C
Rationale: Lactulose reduces ammonia levels to prevent hepatic encephalopathy.
The nurse is assessing a client with suspected meningitis. Which of the following findings would the nurse expect?
- A. Positive Kernig’s sign.
- B. Hypothermia.
- C. Soft, non-tender neck.
- D. Decreased level of consciousness.
Correct Answer: A
Rationale: positive Kernig’s sign (pain and resistance on leg extension) is a classic finding in meningitis
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Document the finding.
- B. Contact the physician.
- C. Elevate the head of the bed.
- D. Administer a pain medication.
Correct Answer: B
Rationale: The vital signs indicate shock, so contacting the physician for immediate intervention is the priority.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler’s position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm)
The nurse is teaching a client with a new diagnosis of heart failure about sodium restriction. Which of the following foods should the client avoid?
- A. Fresh apples.
- B. Canned soups.
- C. Baked chicken.
- D. Brown rice.
Correct Answer: B
Rationale: canned soups are high in sodium, which should be limited in heart failure to prevent fluid retention