Nokea
A client is receiving allopurinol and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following?
- A. Facial swelling is expected in the first few days of therapy.
- B. Drink at least 3000 mL of water per day.
- C. Do not eat while taking this medication.
- D. This medication begins working immediately.
Correct Answer: B
Rationale: Allopurinol requires high fluid intake (3000 mL/day) to prevent kidney stone formation.
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The nurse is caring for a client who is edentulous. Which of the following diet orders should the nurse request from the healthcare provider?
- A. a low sodium diet
- B. a mechanical soft diet
- C. a renal diet
- D. a high-fiber diet
Correct Answer: B
Rationale: A mechanical soft diet is appropriate for an edentulous client to ensure safe chewing and swallowing.
The nurse is caring for a pregnant client at 28 weeks' gestation who presents to the emergency department with signs of preeclampsia. The primary healthcare provider (PHCP) orders magnesium sulfate. What potential complication should the nurse closely monitor for during magnesium sulfate administration?
- A. Pulmonary edema
- B. Hyperglycemia
- C. Hyporeflexia
- D. Increased fetal movement
Correct Answer: C
Rationale: Hyporeflexia is a sign of magnesium toxicity, a critical complication to monitor during administration.
The med-surge nurse receives a report on a client who is legally blind. Which action by the nurse would be most likely to reduce this client's anxiety?
- A. Assign the client to a private room.
- B. Orient the client to their room.
- C. Request for a sitter to be assigned.
- D. Instruct the UAP to check on the client frequently.
Correct Answer: B
Rationale: Orienting a legally blind client to their room reduces anxiety by promoting safety and familiarity.
The emergency department nurse is caring for a client with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The nurse knows that the first-line medication for this presentation is:
- A. Oral diphenhydramine
- B. Nebulized albuterol
- C. Oral prednisone
- D. Parenteral epinephrine
Correct Answer: D
Rationale: Anaphylaxis from a bee sting requires immediate parenteral epinephrine to reverse airway edema and respiratory distress.
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action?
- A. Continue preparing for the procedure in the room.
- B. Notify the chaplain.
- C. Leave the room quietly and come back after 15 minutes to change the client's dressing.
- D. Ask the son if he wants the nurse to join in prayer.
Correct Answer: C
Rationale: Respecting the spiritual moment, leaving the room quietly allows privacy and maintains dignity.