Nokea
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
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A female client is diagnosed with human papillomavirus (HPV).
Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?
- A. I will need to take antibiotics for at least a week.'
- B. I will use only prescribed douches to avoid a recurrence.'
- C. I will return for a Pap smear in six months.'
- D. I will avoid using tampons for eight weeks.'
Correct Answer: C
Rationale: Strategy: Determine the 'hidden meaning' of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct-several strains of the human papillomavirus (HPV) are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome
Which of the following interventions is appropriate when caring for a client who has lost function of cranial nerve $\mathrm{V}$ on the left side?
- A. Helping the client select foods that are easy to swallow
- B. Speaking to the client on his right side
- C. Applying an eye patch to the left eye
- D. Speaking to the client on his left side
Correct Answer: C
Rationale: Cranial nerve V (trigeminal) loss may impair corneal sensation, increasing risk of eye injury; an eye patch protects the left eye. Swallowing and hearing are unrelated.
A man who has diabetes complains of hunger; is pale, shaky, and perspiring; and has cool skin. What is the most appropriate initial action for the nurse?
- A. Call the physician for orders
- B. Give the client cola to drink
- C. Have the client lie down
- D. Administer the next dose of insulin
Correct Answer: B
Rationale: Symptoms indicate hypoglycemia; giving cola provides quick glucose to raise blood sugar. Calling the physician, lying down, or giving insulin delays or worsens the situation.
The nurse is to suction a client. What action is essential prior to inserting the suction catheter?
- A. Clear the mouth and throat of secretions.
- B. Lower the head of the bed.
- C. Oxygenate the client.
- D. Check the suction pressure.
Correct Answer: C
Rationale: Pre-oxygenation prevents hypoxia during suctioning, a critical step. Clearing secretions, lowering the bed, or checking pressure are secondary.
The nurse is caring for a client with a history of asthma who is receiving albuterol via nebulizer. Which of the following findings should the nurse report immediately?
- A. Heart rate of 120 bpm.
- B. Respiratory rate of 20 breaths/min.
- C. Oxygen saturation of 95%.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A heart rate of 120 bpm suggests tachycardia, a serious albuterol side effect. Options B, C, and D are normal or expected.