Nokea
A client has recently been diagnosed with open-angle glaucoma. The nurse should tell the client to avoid taking:
- A. Aleve (naprosyn)
- B. Benadryl (diphenhydramine)
- C. Tylenol (acetaminophen)
- D. Robitussin (guaifenesin)
Correct Answer: B
Rationale: Benadryl, an antihistamine, can increase intraocular pressure, worsening open-angle glaucoma, and should be avoided.
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A client is admitted to the medical-surgical unit with a report of severe hematemesis. The nurse should give priority to:
- A. Performing an assessment
- B. Obtaining a blood permit
- C. Initiating an IV with a large-bore needle
- D. Inserting an NG tube
Correct Answer: C
Rationale: Severe hematemesis indicates significant bleeding, requiring immediate IV access with a large-bore needle for fluid and blood resuscitation to stabilize the client.
A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should
- A. transfuse the RBC as ordered.
- B. administer an antipyretic and transfuse the RBCs.
- C. transfuse the RBCs but monitor the temperature hourly.
- D. not transfuse the RBCs and instead contact the physician.
Correct Answer: D
Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.
A client is receiving end-of-life care and tells the nurse that he has not always lived the way he should have or treated his children well. Which of the following responses is the most appropriate?
- A. What kinds of things have you done?'
- B. There are things that you regret.'
- C. I'm sure those things don't matter anymore.'
- D. It's not too late to ask for forgiveness.'
Correct Answer: B
Rationale: Reflecting that the client has regrets (B) is empathetic and opens further discussion without judgment. Asking for details (A), dismissing concerns (C), or suggesting forgiveness (D) may not be appropriate.
A 19-year-old female comes into the women's clinic for an STD test. The nurse explains all of the following confirmed cases of STDs must be reported to the Centers for Disease Control (CDC) EXCEPT
- A. genital herpes.
- B. chlamydia.
- C. hepatitis B.
- D. gonorrhea.
Correct Answer: A
Rationale: Chlamydia, gonorrhea, and hepatitis B are reportable to the CDC. Genital herpes is not nationally reportable, though local regulations may vary.
A 32-year-old woman comes into the clinic for a well-woman exam and asks for information on an intrauterine device (IUD) for contraception. The nurse should explain that all of the following are potential risks EXCEPT
- A. stroke.
- B. pelvic infections.
- C. abnormal menstrual bleeding.
- D. ectopic pregnancy.
Correct Answer: A
Rationale: IUD risks include pelvic infections, abnormal bleeding, and ectopic pregnancy. Stroke is not a recognized risk associated with IUD use.