A client with a history of peptic ulcer disease is prescribed sucralfate (Carafate). The nurse should instruct the client to:
- A. Take the medication 1 hour before meals.
- B. Take the medication with meals.
- C. Take the medication at bedtime.
- D. Stop the medication if constipation occurs.
Correct Answer: A
Rationale: Sucralfate should be taken 1 hour before meals to coat the stomach lining and protect ulcers.
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A 24-year-old client has been diagnosed with acute osteomyelitis in the left leg. He complains of acute pain in the leg that intensifies when he moves it. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, which of the following nursing diagnoses would be most appropriate for this client?
- A. Grieving related to possible left lower leg amputation.
- B. Activity intolerance related to severe left leg pain.
- C. A disturbed body image related to left leg swelling and inflammation.
- D. Deficient fluid volume related to elevated temperature of 101°F (38.3°C).
Correct Answer: B
Rationale: Activity intolerance due to severe pain is the most appropriate diagnosis, as pain limits mobility. Amputation is not indicated, body image is secondary, and fever does not directly cause fluid volume deficit.
The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown by the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the lower uterus to determine the presenting part, typically performed in the eighth month to assess fetal position.
A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for:
- A. Irritability.
- B. Hyperventilation.
- C. Diarrhea.
- D. Edema.
Correct Answer: B
Rationale: Persistent vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, which can manifest as hyperventilation as the body compensates for elevated pH.
The nurse is assessing a 55-year-old client with chronic obstructive pulmonary disease. The client weighs 200 lb and is 6 feet tall. Using the diagram shown here, the nurse should record in the health history that the client's chest is:
- A. Barrel-shaped
- B. Muscular
- C. Normal for the client's age, height, and weight
- D. Showing the effects of long-term use of bronchodilators
Correct Answer: A
Rationale: A barrel-shaped chest is characteristic of chronic obstructive pulmonary disease due to hyperinflation of the lungs, which is likely in this client. The client's weight and height suggest a normal body habitus, not a muscular chest, and bronchodilator use does not directly cause this chest shape.
The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor closely?
- A. White blood cell count.
- B. Blood glucose levels.
- C. Serum potassium.
- D. Hemoglobin A1c.
Correct Answer: A
Rationale: Chemotherapy can cause bone marrow suppression, requiring close monitoring of white blood cell counts for infection risk.
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