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A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid using aspirin for pain.
- B. I will consume dairy products to increase my calcium intake.
- C. I will drink 1.5 to 2 liters of fluid each day.
- D. I will need to limit my intake of fiber.
Correct Answer: A
Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.
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A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?
- A. Teaching a new mother how to breastfeed.
- B. Assisting a client with ambulation post-surgery.
- C. Helping with medication administration.
- D. Delegating IV medication administration.
Correct Answer: B
Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.
A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You should expect your urine to turn orange while taking this medication.
- C. This medication can cause you to gain weight.
- D. Take this medication with food to reduce gastrointestinal discomfort.
Correct Answer: D
Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.
A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?
- A. Potassium 4.2 mEq/L
- B. Glucose 250 mg/dL
- C. Bicarbonate 20 mEq/L
- D. Sodium 135 mEq/L
Correct Answer: B
Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.
A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?
- A. Turn the client on their side.
- B. Administer an analgesic.
- C. Administer antiemetic.
- D. Monitor the client's vital signs.
Correct Answer: A
Rationale: The correct action the nurse should take first when a client reports nausea in the PACU is to turn the client on their side. This action helps prevent aspiration in a client with nausea, reducing the risk of choking or inhaling vomitus. Administering an analgesic (Choice B) is not the priority in this situation unless pain is the primary cause of nausea. While administering an antiemetic (Choice C) can help relieve nausea, it is not the initial action to prevent aspiration. Monitoring the client's vital signs (Choice D) is important but should come after ensuring the client's safety by turning them on their side.
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?
- A. Do you understand that the voices are not real?
- B. Why do you think the voices are talking to you?
- C. Have you tried going to a private place when this occurs?
- D. What helps you ignore what you are hearing?
Correct Answer: D
Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.