Nokea
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply.
- A. I don't plan on eating any more frozen meals.'
- B. I plan to take my diuretic pill in the morning.'
- C. I will weigh myself at least every other day.'
- D. I'm going to look into joining a cardiac rehabilitation program.'
- E. Ibuprofen works best for me when I have pain.'
Correct Answer: E
Rationale: Ibuprofen can cause fluid retention, worsening heart failure, and requires further teaching. Avoiding frozen meals , morning diuretic , regular weighing , and cardiac rehab are appropriate.
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The perinatal nurse is reviewing telephone messages from clients. The nurse should first telephone the client who is at
- A. 18 weeks gestation, is taking ceftriaxone, and reports mild diarrhea
- B. 22 weeks gestation and is taking acetaminophen twice daily
- C. 28 weeks gestation, is taking metronidazole, and reports dark colored urine
- D. 32 weeks gestation and is taking ibuprofen daily
Correct Answer: D
Rationale: Ibuprofen at 32 weeks gestation is concerning due to risks of premature ductus arteriosus closure and oligohydramnios, requiring immediate follow-up. Mild diarrhea and dark urine with metronidazole are less urgent, and acetaminophen is safe.
The drug of choice for managing status epilepticus is:
- A. Carbamazepine (Tegretol)
- B. Diazepam (Valium)
- C. Clonazepam (Klonopin)
- D. Valproic acid (Depakene)
Correct Answer: B
Rationale: Diazepam is the first-line treatment for status epilepticus due to its rapid onset in stopping seizures.
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
- A. Temperature of 99.5 degrees Fahrenheit with painful urination
- B. An open, reddened wound on the heel
- C. Insomnia and daytime fatigue
- D. Nausea with 2 episodes of vomiting
Correct Answer: B
Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.
A client with Parkinson's disease complains of 'choking' when he swallows. Which intervention will improve the client's ability to swallow?
- A. Withholding liquids until after meals
- B. Providing semi-liquids when possible
- C. Providing a full liquid diet
- D. Offering small, more frequent meals
Correct Answer: B
Rationale: Semi-liquids are easier to swallow for Parkinson's patients with dysphagia. Withholding liquids risks dehydration. Full liquid diets may be too thin. Small meals help nutrition but not swallowing.
Laboratory Reference Range
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
The nurse has received information from unlicensed assistive personnel about assigned client situations. Which of the following situations should the nurse address first?
- A. Client who has type 1 diabetes mellitus and a fasting capillary blood glucose level of 90 mg/dL (5.0 mmol/L)
- B. client who is collecting a 24-hour urine specimen and discarded the last void by mistake
- C. client who is requesting clarification about the diagnostic procedure that is scheduled to begin in 4 hours
- D. client who was recently admitted to a room that has a full sharps disposal container on the wall
Correct Answer: D
Rationale: A full sharps container poses an immediate safety hazard and must be addressed first. Normal glucose , a discarded void , and procedure clarification are less urgent.