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A client with a history of Parkinson's disease is prescribed levodopa/carbidopa (Sinemet). Which instruction should the nurse include?
- A. Take it with high-protein meals
- B. Avoid driving if drowsy
- C. Take it at bedtime only
- D. Crush the tablet for faster absorption
Correct Answer: B
Rationale: Levodopa/carbidopa can cause drowsiness, so clients should avoid driving if affected to ensure safety.
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Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
- A. Tinnitus
- B. Ecchymoses
- C. Increased pulse rate
- D. Decreased blood pressure
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
- A. Evidence of ruptured membranes.
- B. Viability status of the fetus.
- C. Indications that contractions have ceased.
- D. Fetal heart rate variability.
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
The sense of hearing is assessed using which standardized test?
- A. The Taylor test
- B. The Rinne test
- C. The Babinski test
- D. The APGAR test
Correct Answer: B
Rationale: The Rinne test is a standardized test used to assess hearing by comparing air and bone conduction using a tuning fork.
The nurse should consider which of the following principles when developing a plan of care to manage a client's pain from cancer?
- A. Individualize the pain medication regimen for the client.
- B. Select medications that are least likely to lead to addiction.
- C. Administer pain medication as soon as the client requests it.
- D. Change pain medications periodically to avoid drug tolerance.
Correct Answer: A
Rationale: Individualizing the regimen ensures effective pain control tailored to the client's needs, considering cancer pain's variable nature.
The nurse should instruct a client who is taking dexamethasone (Decadron) and furosemide (Lasix) to report:
- A. Excitability.
- B. Muscle weakness.
- C. Diarrhea.
- D. Increased thirst.
Correct Answer: B
Rationale: Muscle weakness is a serious side effect of dexamethasone (steroid-induced myopathy) and furosemide (potassium loss), requiring prompt reporting.