Nokea
A client with angina shows the nurse her nitroglycerin (Nitrostat) that she carries in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept in:
- A. The refrigerator.
- B. A cool, moist place.
- C. A dark container to shield from light.
- D. A plastic bag where it is readily available.
Correct Answer: C
Rationale: Nitroglycerin is sensitive to light and heat, which can degrade its potency. Storing it in a dark container protects it from light exposure, ensuring effectiveness.
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When creating a program to decrease the primary cause of disability and death in children, which of the following is most effective for the community health nurse to do?
- A. Encourage state legislators to draft legislation to promote prenatal care.
- B. Recommend that the health department make immunizations available at no cost to all children.
- C. Teach health and safety practices to children and their parents.
- D. Have a nurse practitioner hired for each of the schools in the community.
Correct Answer: B
Rationale: Free immunizations address the leading cause of preventable childhood disability and death by ensuring widespread protection against infectious diseases.
A client diagnosed with refractory myasthenia gravis is told by the primary health care provider that plasmapheresis therapy is indicated. When the client asks the nurse to repeat the primary health care provider's reason for prescribing this treatment, the nurse should tell the client that this therapy will most likely improve which problem?
- A. Double vision
- B. Difficulty breathing
- C. Urinary incontinence
- D. Prickling sensation in the legs
Correct Answer: B
Rationale: Plasmapheresis is a process that separates the plasma from the blood elements so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually 3 to 5 treatments are required. This therapy is not indicated for the reasons listed in any of the other options.
A 20-year-old single parent brings her 3-year-old son into the emergency department because he 'fell.' The child has bruises on his face, arms, and legs; his mother says that she did not witness the fall. The nurse suspects child abuse. While examining the child, the mother says, 'Sometimes I guess I'm pretty rough with him. I'm alone, and I just don't know how to manage him.' The nurse should ask the mother if she would find it helpful to have a referral to:
- A. A program for single parents.
- B. A parenting education program.
- C. A women's support group.
- D. A support group for abusive parents.
Correct Answer: B
Rationale: A parenting education program would provide the mother with skills to manage her child's behavior appropriately, addressing potential abuse triggers and improving parenting techniques.
When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications?
- A. Essential amino acid deficiency.
- B. Essential fatty acid deficiency.
- C. Hyperglycemia.
- D. Infection.
Correct Answer: C,D
Rationale: TPN can cause hyperglycemia due to high glucose content and infection due to catheter use, both requiring vigilant monitoring.
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: The nurse should fi rst determine why the client wants to sit up, and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising theside rails and elevating the head of the bed do not address the client’s needs.