A client with angina has been taking nifedipine. The nurse should teach the client to:
- A. Monitor blood pressure monthly.
- B. Perform daily weights.
- C. Inspect gums daily.
- D. Limit intake of green leafy vegetables.
Correct Answer: C
Rationale: Nifedipine, a calcium channel blocker, can cause gingival hyperplasia. Daily gum inspection helps detect this side effect early.
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A client developed shock after a severe myocardial infarction and has now developed acute renal failure. The nurse should base the response on the knowledge that there was:
- A. A decrease in the blood flow through the kid-
- B. An obstruction of urine flow from the kidneys.
- C. A blood clot formed in the kidneys.
- D. A structural damage to the kidney resulting in acute tubular necrosis.
Correct Answer: A
Rationale: Decreased renal blood flow from shock post-myocardial infarction reduces kidney perfusion, leading to acute renal failure.
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
- A. Incorporate physical exercise as tolerated into the daily routine.
- B. Monitor peak flow numbers after meals and at bedtime.
- C. Eliminate stressors in the work and home environment.
- D. Use sedatives to ensure uninterrupted sleep at night.
Correct Answer: A
Rationale: Regular exercise, as tolerated, improves lung function and overall health in asthma. Peak flow monitoring is typically done morning and evening. Eliminating all stressors is unrealistic. Sedatives may depress respiration and are not recommended.
The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which of the following clients would not have delayed fluid restrictions?
- A. The client who has undergone a bronchoscopy under local anesthesia.
- B. The client who has undergone a transurethral resection of a bladder tumor under general anesthesia.
- C. The client who has undergone a repair of carpal tunnel syndrome under local anesthesia.
- D. The client who has undergone an inguinal herniorrhaphy with spinal and intravenous conscious sedation.
Correct Answer: A,C
Rationale: Local anesthesia (bronchoscopy, carpal tunnel repair) does not affect swallowing reflexes, so fluids are not delayed. General or spinal anesthesia (B, D) impairs swallowing, requiring delayed fluid intake.
The son of a 78-year-old client with metastatic prostate cancer is asking the nurse about the purpose of hospice care. Which of the following statements by the nurse best describes hospice care?
- A. Hospice care uses a team approach to direct hospice activity.
- B. Clients and their families are the focus of care.
- C. The client's physician coordinates all the care.
- D. All hospice clients will die at home.
Correct Answer: B
Rationale: Hospice care focuses on the client and family, providing holistic support to enhance quality of life and comfort during the end-of-life phase.
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