Nokea
A client with angina is experiencing migraine headaches. The physician has prescribed sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Consult with the RN before administration.
- B. Try to obtain samples for the client to take home.
- C. Perform discharge teaching regarding this drug.
- D. Consult social services for financial assistance with obtaining the drug.
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which could exacerbate cardiac ischemia. Consulting the RN to verify the order is the most appropriate action. Obtaining samples, discharge teaching, or consulting social services do not address the safety concern, so answers B, C, and D are incorrect.
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A pregnant diabetic client, who is 37 weeks gestation, is scheduled for an amniocentesis. The client asks the nurse the purpose of the test. The nurse should explain that the primary reason for performing an amniocentesis is:
- A. To determine the effect of the diabetes on the fetus
- B. To estimate the skeletal age of the fetus
- C. To determine the fetal lung maturity
- D. To obtain information about aberrant fetal genes
Correct Answer: C
Rationale: At 37 weeks, amniocentesis primarily assesses fetal lung maturity via lecithin/sphingomyelin ratio, critical for delivery planning. Diabetes effects , skeletal age , and genetic issues are less common indications.
The nurse is caring for a client with a history of peptic ulcer disease.
- A. Which dietary instruction is most appropriate for a client with peptic ulcer disease?
- B. Avoid spicy foods and caffeine.
- C. Eat large meals three times daily.
- D. Consume high-fat foods to coat the stomach.
- E. Drink alcohol in moderation.
Correct Answer: A
Rationale: Avoiding spicy foods and caffeine reduces gastric irritation in peptic ulcer disease. Small, frequent meals are preferred, high-fat foods delay healing, and alcohol exacerbates ulcers.
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist client to turn, deep breathe and cough
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.
The nurse is caring for a client with a history of eating disorders.
- A. Which client statement indicates a need for further teaching about anorexia nervosa?
- B. I need to gain weight slowly to stay healthy.'
- C. I can stop dieting once I reach my goal weight.'
- D. I should eat balanced meals regularly.'
- E. I need support to change my eating habits.'
Correct Answer: B
Rationale: Stating that dieting can stop at a goal weight suggests a misunderstanding, as anorexia requires ongoing nutritional and psychological management. Slow weight gain, balanced meals, and support are correct.
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.