Nokea
A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is appropriate reinforcement of information by the nurse?
- A. Drink at least 8 glasses of water a day.
- B. Be sure to take the medication with food.
- C. It is safe to take with oral contraceptives.
- D. Stop the medication after 5 days.
Correct Answer: A
Rationale: Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim.
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The nurse is caring for clients in outpatient surgery.
- A. What is the best statement by the nurse to the mother of a four-year-old preparing for eye surgery?
- B. Draw a picture of the eye to explain what will happen.'
- C. Tell your daughter that the procedure will take one hour.'
- D. Use dolls or puppets to explain how to get ready for surgery.'
- E. Read an age-appropriate illustrated book about eye surgery to your daughter.'
Correct Answer: C
Rationale: For a four-year-old, using dolls or puppets to demonstrate the procedure in simple terms is developmentally appropriate, addressing what the child will experience (see, hear, feel). Drawing pictures or reading books is better for school-aged children, and time concepts like one hour are not relatable to preschoolers.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
- A. Which intervention should the nurse include in the care plan for a client with COPD?
- B. Encourage a high-protein, low-carbohydrate diet.
- C. Administer oxygen at 6 liters per minute via nasal cannula.
- D. Teach the client to use pursed-lip breathing.
- E. Place the client in a supine position to promote rest.
Correct Answer: C
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and improving oxygenation in COPD. High-protein diets are beneficial but secondary, high-flow oxygen risks CO2 retention, and supine positioning impairs breathing.
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
A child at summer camp comes to see the camp nurse 10 minutes after being stung by a bee. The child complains of tingling around her mouth and tightness in her chest. The nurse's first action is summon help and to:
- A. Administer $\mathrm{O}_2$ at $4 \mathrm{~L} / \mathrm{min}$ by nasal cannula.
- B. Apply a tourniquet proximal to the bee sting and give epinephrine subcutaneously.
- C. Administer $\mathrm{O}_2$ at $6 \mathrm{~L} / \mathrm{min}$ and give Benadryl (Diphenhydramine) $25 \mathrm{mg}$ PO.
- D. Reassure the child that she is only excited due to the sting.
Correct Answer: B
Rationale: Tingling and chest tightness suggest anaphylaxis; epinephrine is the first-line treatment, and a tourniquet may slow venom spread.
The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?
- A. Solid foods should be introduced at 3-4 months
- B. Whole milk is difficult for a young infant to digest
- C. Fluoridated tap water should be used to dilute milk
- D. Supplemental apple juice can be used between feedings
Correct Answer: B
Rationale: Cow's milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load.