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A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed theophylline. The nurse should monitor the client for which of the following adverse effects?
- A. Tachycardia.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Weight loss.
Correct Answer: A
Rationale: Theophylline can cause tachycardia due to its stimulant effects.
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The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse should tell the client to be especially alert for which problem?
- A. Hair loss
- B. Weight loss
- C. Hypotension
- D. Signs of infection
Correct Answer: D
Rationale: Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication and report them to the primary health care provider if experienced. The client is also taught about other side/adverse effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints. Some weight loss may occur, but this is not as significant as the onset of an infection.
You assess your family as having a deficit in terms of their instrumental activities of daily living (ADLs). Which healthcare professional would you most likely refer this family to in order to address this deficit?
- A. A social worker
- B. A physical therapist
- C. An occupational therapist
- D. A speech therapist
Correct Answer: C
Rationale: Occupational therapists specialize in helping individuals improve their ability to perform instrumental activities of daily living (e.g., managing finances, cooking), making them the most appropriate referral for this deficit.
The nurse is assessing teenaged girls at a well child clinic. The nurse should describe the girl shown in the figure as having:
- A. Normal posture
- B. Kyphosis
- C. Scoliosis
- D. Lordosis
Correct Answer: C
Rationale: Scoliosis is characterized by a lateral curvature of the spine, which may be observed in a teenager. Kyphosis involves forward curvature, lordosis involves inward lumbar curvature, and normal posture lacks these abnormalities.
The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized 'hand off' change of shift reporting. Which of the following is a standardized 'hand off' change of shift reporting system that you may want to consider for implementation on your nursing care unit?
- A. The Four P's
- B. UBAR
- C. ISBAR
- D. MAUMAR
Correct Answer: C
Rationale: ISBAR is a standardized hand-off reporting system (Introduction, Situation, Background, Assessment, Recommendation) recommended by The Joint Commission for effective communication during shift changes.
The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?
- A. The American Nurses Association's Scopes of Practice
- B. The American Nurses Association's Standards of Care
- C. State statutes
- D. Federal law
Correct Answer: C
Rationale: Delegation of tasks by a registered nurse must comply with state statutes , which define the scope of practice and delegation authority for nurses and other healthcare team members within each state. These laws ensure that tasks are delegated to individuals who are legally qualified to perform them.