Nokea
A client with iron deficiency anemia is started on ferrous sulfate tablets. The nurse has instructed the client on the appropriate way to take her medication. Which of the following statements indicates that the client understands the nurse's teaching?
- A. I can take my iron tablets with a glass of milk.'
- B. I need to take my iron tablets daily before breakfast.'
- C. Taking my iron tablets before I go to bed will cut down on stomach upset.'
- D. Taking my iron tablets with a glass of orange juice will help me absorb more of the medicine.'
Correct Answer: D
Rationale: Vitamin C (in orange juice) enhances iron absorption. Milk reduces absorption, and timing (breakfast or bedtime) is less critical.
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The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply.
- A. Do not travel by car or airplane for at least 3-4 weeks
- B. Drink plenty of fluids daily and limit caffeine and alcohol intake
- C. Elevate legs on a footstool when sitting and dorsiflex the feet often
- D. Resume the walking or swimming exercise program as soon as possible after getting home
- E. Sit in a cross-legged yoga position for 5-10 minutes as this benefits circulation
Correct Answer: B,C,D
Rationale: To prevent DVT recurrence: stay hydrated to reduce blood viscosity, elevate legs and dorsiflex to promote venous return, and resume exercise to enhance circulation. Travel restrictions are not absolute post-resolution, and cross-legged sitting impedes venous flow.
The nurse caring for a client with myasthenia gravis is reviewing the nursing care plan. Which is recognized as the priority nursing diagnosis?
- A. Risk for injury
- B. Acute pain
- C. Ineffective airway clearance
- D. Impaired mobility
Correct Answer: C
Rationale: Clients with myasthenia gravis have problems with the muscular activity of breathing. Answers A, B, and D are not the priority, so they are wrong.
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
- A. Determine that adequate mist is supplied
- B. Inspect the nares and ears for skin breakdown
- C. Lubricate the tips of the cannula before insertion
- D. Maintain sterile technique when handling cannula
Correct Answer: B
Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.
The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?
- A. I can leave right after the shot as I didn't have a reaction last time.'
- B. I will be back in a week for my next allergy shot.'
- C. I will let the doctor know if I get any itchy hives tonight.'
- D. It is okay if I have some redness at the injection site tonight.'
Correct Answer: A
Rationale: Leaving immediately after an allergy shot is unsafe due to the risk of delayed anaphylaxis, requiring a 20–30 minute observation period. Weekly shots , reporting hives , and mild redness are appropriate.
The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply.
- A. Apply the patch when the ship starts moving and not before.'
- B. Dispose of the patch out of reach of children and pets.'
- C. Ensure that the old patch is removed before applying a new one.'
- D. Place the patch on a hairless, clean, dry area behind the ear.'
- E. Wash your hands with soap and water after handling the patch.'
Correct Answer: B,C,D,E
Rationale: Appropriate scopolamine instructions include safe disposal , removing old patches , correct placement , and hand washing . Applying the patch only when moving is incorrect, as it should be applied hours before travel.