Nokea
A client with a history of depression is prescribed trazodone (Desyrel). The nurse should instruct the client to take the medication:
- A. In the morning to avoid sedation.
- B. At bedtime to promote sleep.
- C. With meals to enhance absorption.
- D. As needed for low mood.
Correct Answer: B
Rationale: Trazodone is sedating and should be taken at bedtime to promote sleep and manage depression.
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A nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician immediately?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Jaundice on the face
Correct Answer: D
Rationale: Jaundice within 24 hours of birth is pathological and requires immediate evaluation. Milia, Mongolian spots, and caput succedaneum are normal findings.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed fluticasone (Flovent). The nurse should instruct the client to:
- A. Rinse the mouth after inhalation.
- B. Use the inhaler as needed for shortness of breath.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: A
Rationale: Rinsing the mouth after fluticasone inhalation prevents oral thrush.
Which action by the new nurse when initiating continuous electrocardiogram (ECG) monitoring on a client should indicate to the registered nurse the need for further teaching?
- A. Clipping small areas of hair under the area planned for electrode placement
- B. Stating the need to change the electrodes and inspect the skin every 24 hours
- C. Stating the need to use hypoallergenic electrodes for clients who are sensitive
- D. Cleansing the skin with povidone-iodine (Betadine) before applying the electrodes
Correct Answer: D
Rationale: The skin is cleansed with soap and water (not povidone-iodine), denatured with alcohol, and allowed to air-dry before electrodes are applied. The other three options are correct measures.
A client has begun medication therapy with pancrelipase. The nurse should educate the client to expect which occurrence from this medication?
- A. Relieve of heartburn
- B. Eliminate of abdominal pain
- C. Help regulating blood glucose
- D. Decrease in the amount of fat in the stools
Correct Answer: D
Rationale: Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. It does not regulate blood glucose; this is a function of insulin, a hormone produced in the beta cells of the pancreas.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.