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A client with a history of heart failure is prescribed carvedilol (Coreg). The nurse should instruct the client to:
- A. Monitor blood pressure regularly.
- B. Take the medication with meals.
- C. Avoid potassium-rich foods.
- D. Stop the medication if dizziness occurs.
Correct Answer: A
Rationale: Carvedilol can cause hypotension, requiring regular blood pressure monitoring.
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The mother of a child with moderate diarrhea asks how to manage her child's illness. Which of the following should the nurse suggest?
- A. Begin clear liquids for 24 hours.
- B. Feed the child bananas, rice, applesauce, and toast.
- C. Offer foods that are low in fat.
- D. Continue the child's regular diet.
Correct Answer: B
Rationale: The BRAT diet (bananas, rice, applesauce, toast) is recommended for moderate diarrhea in children to provide easily digestible, low-fiber foods that help firm stools.
The nurse is assessing a neonate born to a diabetic mother. Which of the following findings should the nurse expect to see in the infant?
- A. Hypertonia
- B. Hyperactivity
- C. Large size
- D. Scaly skin
Correct Answer: C
Rationale: Neonates born to diabetic mothers are often macrosomic (large size) due to maternal hyperglycemia. Hypertonia, hyperactivity, and scaly skin are not typical findings.
A client with a fracture is placed in skeletal traction. What is the nurse's priority assessment?
- A. Skin integrity at pin sites.
- B. Range of motion in the affected limb.
- C. Pain level during movement.
- D. Muscle strength in the unaffected limb.
Correct Answer: A
Rationale: Monitoring skin integrity at pin sites is critical to detect infection or tissue breakdown in skeletal traction.
The nurse is caring for a client who has just undergone a tonsillectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage frequent swallowing.
- B. Monitor for excessive swallowing.
- C. Offer ice chips immediately.
- D. Keep the head of the bed flat.
Correct Answer: B
Rationale: Monitoring for excessive swallowing is critical post-tonsillectomy, as it may indicate bleeding from the surgical site.
A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, 'All this work with her has been useless. She's just going back to him as usual.' Which of the following statements by a nursing colleague would be most helpful to this nurse?
- A. Her reasons for staying are complex. She can leave only when she is ready and can be safe.'
- B. I know it is frustrating to work with clients who don't follow our advice.'
- C. I need to do you have her again and have another chance.'
- D. These women almost never leave for good because of their emotional and financial dependency.'
Correct Answer: A
Rationale: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism.