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A client with a history of bipolar disorder is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following side effects?
- A. Weight loss.
- B. Agranulocytosis.
- C. Hyperglycemia.
- D. Dry skin.
Correct Answer: B
Rationale: Carbamazepine can cause agranulocytosis, requiring regular monitoring of white blood cell counts.
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The nurse is teaching a client with hypertension about dietary modifications. Which statement by the client indicates understanding of the teaching?
- A. I should increase my intake of processed foods.'
- B. I will limit my sodium intake to 2,300 mg per day.'
- C. I can drink coffee as much as I want.'
- D. I should avoid fruits like bananas.'
Correct Answer: B
Rationale: Limiting sodium to 2,300 mg per day or less helps manage hypertension by reducing fluid retention and blood pressure.
The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal delivery. Which of the following findings should be reported to the physician?
- A. A scant amount of maternal lochia serosa.
- B. The presence of a neonatal tonic neck reflex.
- C. A nonpalpable maternal fundus.
- D. Neonatal central cyanosis.
Correct Answer: D
Rationale: Neonatal central cyanosis indicates possible respiratory or cardiac issues and requires immediate reporting. The other findings are normal at 1 week postpartum.
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
- A. Pleuritic chest pain has resolved.
- B. The oxygen saturation is greater than 92%.
- C. Fluctuations in the water-seal chamber ceased.
- D. Suction in the chest drainage system is no longer needed.
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.
A client with a history of hypothyroidism is admitted with fatigue. The nurse should monitor the client for which of the following laboratory abnormalities?
- A. Elevated thyroid-stimulating hormone (TSH).
- B. Decreased free T4.
- C. Elevated T3.
- D. Decreased TSH.
Correct Answer: A, B
Rationale: Hypothyroidism presents with elevated TSH and decreased free T4.
How many mL of a liquid medication would you administer intramuscularly using the below information? Doctor's order: 10 mg of medication BID Medication label: 1 mL = 12 mg
- A. 0.8 mL
- B. 0.9 mL
- C. 0.75 mL
- D. 0.125 mL
Correct Answer: A
Rationale: To calculate: 10 mg ÷ 12 mg/mL = 0.833 mL, rounded to 0.8 mL for practical administration.