Nokea
A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin to treat angina. Which statement by the client indicates that further teaching is required?
- A. I may experience flushing but will continue to take the medication as prescribed.
- B. I should lie down before taking the medication.
- C. I should not swallow the tablet.
- D. I will wait to call 911 if I don't experience relief after the third tablet.
Correct Answer: D
Rationale: Delaying 911 after three doses (D) is dangerous; clients should call after no relief from the first dose or after three doses (5 minutes apart). Flushing (A), lying down (B), and not swallowing (C) are correct.
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The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- A. Question the order.
- B. Administer the medications.
- C. Administer them separately.
- D. Contact the pharmacy.
Correct Answer: B
Rationale: Lisinopril and furosemide are commonly prescribed together for hypertension, as lisinopril is an ACE inhibitor that reduces blood pressure, and furosemide is a diuretic that reduces fluid volume. There is no contraindication for administering them concomitantly, so answer A is incorrect. Administering them separately is unnecessary, so answer C is incorrect. Contacting the pharmacy is not needed unless there is a supply issue, so answer D is incorrect.
The nurse is caring for a client suspected of having hepatitis A. Which item in the client's history is most likely related to the development of hepatitis A?
- A. The client donated blood three weeks ago.
- B. The client just returned from a trip to India.
- C. The client received a transfusion six months ago.
- D. The client had a cholecystectomy six months ago.
Correct Answer: B
Rationale: Hepatitis A is transmitted via the fecal-oral route, often in areas with poor sanitation like parts of India. Blood donation, transfusions, or cholecystectomy are not typical risk factors.
The nurse is caring for a client who has chickenpox with open lesions. Which of the following infection control precautions should the nurse implement?
- A. Place the client in a private room with monitored negative air pressure.
- B. Ensure that pregnant staff members are not assigned to care for the client.
- C. Put a surgical mask on the client during transport outside of the assigned room.
- D. Wear a protective gown, clean gloves, and an N95 respirator mask when caring for the client.
- E. Prevent visitors from entering the client's room for 24 hours from the initial appearance of symptoms.
Correct Answer: A,B,C,D
Rationale: Chickenpox requires airborne and contact precautions: negative pressure room (A), protecting pregnant staff (B), masking during transport (C), and gown, gloves, N95 (D). Visitor restriction (E) is too short; it lasts until lesions crust.
The nurse supporting a family who has just experienced a sudden and unexpected death needs to know:
- A. that survivors have greater emotional turmoil and shock than when death is expected.
- B. that survivors have less emotional turmoil and shock than when death is expected.
- C. that survivors have the same emotional turmoil and shock as when death is expected.
- D. that survivors have little emotional turmoil and shock because they were not there.
Correct Answer: A
Rationale: Sudden death produces greater emotional turmoil and shock in survivors than does a gradual, expected death.
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?
- A. Conduct guided imagery or distraction
- B. Ensure that the stump is elevated the first day post-op
- C. Wrap the stump snugly in an elastic bandage
- D. Administer opioid narcotics as ordered
Correct Answer: B
Rationale: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.