Nokea
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? 'Take Fosamax
- A. on an empty stomach.'
- B. after meals.'
- C. with calcium.'
- D. with milk 2 hours after meals.'
Correct Answer: A
Rationale: Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.
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The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
- A. Leave the graft site open to the air.
- B. Elevate the recipient site.
- C. Encourage range-of-motion exercises.
- D. Change the dressing twice a day.
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
The newborn infant of an HIV-positive mother is admitted to the nursery.
- A. What should the nurse include in the plan of care for a newborn of an HIV-positive mother?
- B. Standard precautions.
- C. Test ing for HIV.
- D. Transfer to an acute care nursery facility.
- E. Request AZT from the pharmacy.
Correct Answer: A
Rationale: Standard precautions are the immediate priority to protect staff and others from potential HIV transmission. HIV Test ing and AZT may be considered later, and transfer is unnecessary without clinical indication.
A client with a reactive depression has the greaTest chance of success in activities that require psychic and physical energy if the nurse schedules activities in the
- A. morning hours.
- B. middle of the day.
- C. afternoon hours.
- D. evening hours.
Correct Answer: A
Rationale: client with reactive depression has the highest level of physical and psychic energy in the morning
Which response, if made by the client, would indicate that the nurse's teaching about the medication has been effective?
- A. I can join my wife in a glass of wine with our dinner when we eat in a restaurant.'
- B. I should avoid milk and dairy products when I take this pill.'
- C. I should call my doctor if my stools turn very dark.'
- D. I don't like to take pills so I will crush the pill and add it to some applesauce.'
Correct Answer: C
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a true statement. (1) alcohol increases risk of GI bleeding (2) should be taken with food, milk, or antacid to decrease GI upset (3) correct-NSAIDS can cause GI bleeding (4) enteric-coated tablet should not be broken
The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
- A. Bronchial breath sounds in outer lung fields
- B. Decreased tactile fremitus
- C. Hacking, nonproductive cough
- D. Hyper-resonance of areas of consolidation
Correct Answer: A
Rationale: Bronchial breath sounds in outer lung fields. Consolidated lung tissue in pneumonia transmits bronchial breath sounds to outer lung fields.