Nokea
A client with a diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). The nurse should teach the client to take the medication:
- A. On an empty stomach.
- B. With meals to reduce side effects.
- C. At bedtime to promote sleep.
- D. As needed for muscle weakness.
Correct Answer: B
Rationale: Pyridostigmine should be taken with food to reduce gastrointestinal side effects like nausea.
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The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?
- A. Place paper towels over the drops of liquid.
- B. Don clean gloves and wipe up the drops of liquid.
- C. Post 'wet floor' signs around the area.
- D. Call the Environmental Services Department.
Correct Answer: C
Rationale: Posting 'wet floor' signs first ensures immediate safety by alerting others to the hazard, preventing slips. Then, the nurse can proceed with cleanup or notify appropriate personnel.
Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client?
- A. Administer oxygen therapy as needed to maintain adequate oxygenation.
- B. Offer pain medication before having the client deep-breathe and use incentive spirometry.
- C. Encourage the client to cough, deep-breathe, and turn in bed and to 2,000 mL every 24 hours.
- D. Encourage the client to cough, deep-breathe, and turn in bed every 2 hours.
Correct Answer: B
Rationale: Pain control is essential to enable effective deep breathing and incentive spirometry, which prevent atelectasis and pneumonia by promoting lung expansion. Oxygen and fluid intake are supportive but secondary.
The nurse is teaching a client with a new diagnosis of asthma about the use of a spacer with a metered-dose inhaler. Which of the following instructions is most important?
- A. Shake the inhaler before attaching it to the spacer.
- B. Inhale quickly to maximize drug delivery.
- C. Clean the spacer with soap and water weekly.
- D. Use the spacer only during an asthma attack.
Correct Answer: C
Rationale: Cleaning the spacer weekly prevents bacterial buildup, ensuring safe and effective medication delivery.
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
A postoperative client has a Jackson-Pratt drain. Which finding should the nurse report immediately?
- A. Clear, serous drainage.
- B. Bright red drainage of 50 mL in 2 hours.
- C. Slight swelling around the drain site.
- D. Drainage with a foul odor.
Correct Answer: B
Rationale: Bright red drainage suggests active bleeding, a serious complication requiring immediate reporting.