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A client with a diagnosis of bipolar disorder is taking lithium. What is the most important information the nurse should provide?
- A. Take the medication on an empty stomach
- B. Monitor sodium intake
- C. Report any signs of weight gain
- D. Avoid excessive caffeine intake
Correct Answer: B
Rationale: The correct answer is B. Sodium levels can affect lithium levels in the body, so it is crucial to monitor sodium intake to prevent toxicity or subtherapeutic levels. Lithium is typically taken on an empty stomach to enhance absorption, making choice A more accurate than the original 'Take the medication with food.' Reporting weight gain, as mentioned in choice C, is important for monitoring side effects but is not as critical as ensuring proper lithium levels through sodium intake monitoring. Choice D, avoiding excessive caffeine intake, is not a priority concern directly related to lithium therapy.
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The healthcare provider is preparing to administer an intramuscular injection to an adult client. Which site is the preferred location for this injection?
- A. Deltoid muscle.
- B. Vastus lateralis muscle.
- C. Ventrogluteal muscle.
- D. Dorsogluteal muscle.
Correct Answer: C
Rationale: The ventrogluteal site is preferred for intramuscular injections in adults due to its muscle mass and lower risk of nerve injury. The deltoid muscle is more commonly used for vaccines in adults, the vastus lateralis muscle is preferred in infants and young children, and the dorsogluteal muscle is associated with a higher risk of nerve injury and is no longer recommended for intramuscular injections.
The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?
- A. Elevated AST and ALT levels
- B. Decreased albumin level
- C. Elevated bilirubin level
- D. Prolonged PT/INR
Correct Answer: D
Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.
When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?
- A. Use sterile technique for catheter care
- B. Ensure the catheter bag is below the level of the bladder
- C. Provide perineal care daily
- D. Change the catheter only when necessary
Correct Answer: B
Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.
The nurse is teaching a client with diabetes about foot care. Which instruction is most important to prevent complications?
- A. Soak feet in warm water daily
- B. Apply moisturizer between the toes
- C. Wear cotton socks
- D. Inspect feet daily for cuts or sores
Correct Answer: D
Rationale: The correct answer is D: Inspect feet daily for cuts or sores. Daily foot inspection is crucial for clients with diabetes to detect early signs of injury or infection. Soaking feet in warm water daily (choice A) can lead to skin maceration, making the skin more susceptible to breakdown. Applying moisturizer between the toes (choice B) can increase moisture and the risk of fungal infections. While wearing cotton socks (choice C) is beneficial for diabetic foot care, it is not as crucial as daily foot inspections to prevent complications.
A client who is 24 weeks pregnant presents with a complaint of feeling dizzy when lying on her back. What is the best response by the nurse?
- A. Advise the client to lie on her side
- B. Encourage the client to drink more fluids
- C. Suggest the client elevate her legs when lying down
- D. Recommend the client take short walks throughout the day
Correct Answer: A
Rationale: The correct answer is to advise the client to lie on her side. Lying on the side can prevent the compression of the vena cava, which can cause dizziness in pregnant women. Encouraging the client to drink more fluids (Choice B) may be beneficial for other conditions but is not the best response for dizziness when lying on her back. Suggesting the client elevate her legs when lying down (Choice C) is not directly related to the issue described by the client. Recommending the client take short walks throughout the day (Choice D) may be helpful for other pregnancy-related symptoms but is not the most appropriate action for dizziness when lying on her back.