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A client with a history of chronic renal failure is prescribed epoetin alfa (Epogen). The nurse should monitor the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hypoglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Epoetin alfa can cause hypertension due to increased red blood cell production, requiring close monitoring.
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The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply.
- A. Amount of alcohol consumed daily.
- B. Use of antacids.
- C. Dietary intake of fiber.
- D. Use of Vitamin K supplements.
- E. Intake of fruit juices.
Correct Answer: A, B
Rationale: Excessive alcohol consumption and frequent antacid use (which may contain aluminum, reducing calcium absorption) are risk factors for osteoporosis. Fiber, vitamin K, and fruit juices are less relevant.
The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antepartal unit and has the following orders and tasks to complete prior to 7 a.m. The nurse should complete the tasks in which order?
- A. Check documentation, final check of each client.
- B. Fetal monitor strip for 1/2 hour q shift.
- C. Magnesium sulfate drawn at 6 a.m.
- D. Accucheck and sliding scale insulin due at 7, 11, 4, and hs.
Correct Answer: D,G,F,A
Rationale: To manage time effectively: Check documentation and final client checks at 6:30 to ensure all records are complete (A); perform the fetal monitor strip from 6:00 to 6:30 to meet the half-hour requirement (F); draw magnesium sulfate at 6:00 to align with the ordered time (G); perform Accucheck and insulin at 7:00 as per the schedule (D).
Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
- A. Remove any dentures.
- B. Remove contact lenses.
- C. Provide access to limited food and drink.
- D. Ensure that the informed consent is signed.
- E. Have the client void before transport to endoscopy.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.
- A. Ask the client to rub lotion over the hands every day after bathing.
- B. Encourage physical activity, such as ambulation.
- C. Provide frequent contacts for communication and socialization.
- D. Provide family education.
- E. Encourage involvement of family and friends.
Correct Answer: A,B,C,E
Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.