Nokea
A client with iron deficiency anemia has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take with a glass of milk to prevent stomach upset.
- B. Take with orange juice to enhance absorption.
- C. Take on an empty stomach to increase absorption.
- D. Take with food to reduce gastrointestinal upset.
Correct Answer: C
Rationale: The correct instruction is to take ferrous sulfate on an empty stomach to increase absorption. This is because taking it with food or dairy products like milk can reduce its absorption. Orange juice is not recommended as it may interfere with the absorption of iron. Taking ferrous sulfate on an empty stomach may cause gastrointestinal upset, but this can be minimized by gradually increasing the dose.
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A patient refused a newly opened fentanyl patch. Which of the following actions should the nurse take?
- A. Ask another nurse to witness the disposal of the new patch
- B. Dispose of the patch in a sharps container
- C. Send the patch back to the pharmacy
- D. Document the refusal and remove the patch
Correct Answer: A
Rationale: When a patient refuses a newly opened fentanyl patch, the nurse should ask another nurse to witness the disposal of the new patch. This action ensures accountability, proper protocol, and prevents any potential diversion or misuse of the medication. Disposing of the patch in a sharps container (Choice B) is not sufficient as it does not address the need for witness accountability. Sending the patch back to the pharmacy (Choice C) may not be appropriate without proper documentation and witness. Simply documenting the refusal and removing the patch (Choice D) may lack the necessary verification of proper disposal.
A nurse is caring for a client who is experiencing dysphagia. Which of the following interventions should the nurse implement?
- A. Administer thickened liquids.
- B. Provide small bites of food.
- C. Encourage the client to eat quickly to avoid fatigue.
- D. Have the client lie supine after meals.
Correct Answer: A
Rationale: The correct intervention for a client with dysphagia is to administer thickened liquids. Thickened liquids help prevent aspiration, which is a common risk for clients with swallowing difficulties. Providing small bites of food (choice B) can help, but the priority is to modify the liquid consistency. Encouraging the client to eat quickly (choice C) is not recommended as it may increase the risk of aspiration and fatigue. Having the client lie supine after meals (choice D) can actually increase the risk of aspiration, especially in clients with dysphagia.
A nurse is reviewing the medication record of a client with chronic kidney disease. Which of the following medications should the nurse question?
- A. Calcium carbonate
- B. Furosemide
- C. Epoetin alfa
- D. Spironolactone
Correct Answer: D
Rationale: The correct answer is D, Spironolactone. Spironolactone is a potassium-sparing diuretic, which may lead to hyperkalemia in clients with chronic kidney disease. Therefore, its use should be questioned in this population. Choice A, Calcium carbonate, is commonly used to manage phosphate levels in chronic kidney disease. Choice B, Furosemide, is a loop diuretic that helps with fluid retention but should be used with caution in kidney disease. Choice C, Epoetin alfa, is a medication used to stimulate red blood cell production in clients with chronic kidney disease and anemia.
A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid eating foods high in potassium.
- B. I will check my blood pressure at least once a week.
- C. I should increase my intake of dairy products.
- D. I should exercise for 30 minutes at least 5 days a week.
Correct Answer: D
Rationale: The correct answer is D. Exercising for 30 minutes at least 5 days a week helps manage hypertension by promoting cardiovascular health. Statements A, B, and C are incorrect. Avoiding foods high in potassium is not necessary unless specifically advised by a healthcare provider. Checking blood pressure once a week is not frequent enough for effective monitoring. Increasing dairy product intake is not a recommended approach to managing hypertension.
A nurse is assessing a client who is at 34 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 140/90 mm Hg
- B. Fasting blood glucose of 120 mg/dL
- C. Urinary output of 40 mL/hr
- D. Weight gain of 2.3 kg (5 lb) in 1 week
Correct Answer: D
Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening gestational hypertension and should be reported to the provider. Sudden weight gain in a client with gestational hypertension can be a sign of fluid retention, which could worsen the hypertension and lead to complications like preeclampsia. The other options, blood pressure of 140/90 mm Hg, fasting blood glucose of 120 mg/dL, and urinary output of 40 mL/hr, are within normal limits for a client with gestational hypertension and do not pose an immediate concern that requires reporting to the provider.