Nokea
A client with osteoporosis is prescribed alendronate (Fosamax). Which instruction should the nurse include?
- A. Take the medication at bedtime.
- B. Remain upright for 30 minutes after taking.
- C. Crush the tablet for easier swallowing.
- D. Take with a full meal.
Correct Answer: B
Rationale: Remaining upright for 30 minutes after taking alendronate prevents esophageal irritation.
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Which assessment is most important for a client with a traumatic brain injury?
- A. Glasgow Coma Scale.
- B. Blood glucose levels.
- C. Electrolyte panel.
- D. Pain assessment.
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
The nurse is planning care for a client who has returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for:
- A. Alteration in renal perfusion
- B. Electrolyte imbalance
- C. Ineffective coping
- D. Wound infection
Correct Answer: A
Rationale: Post-aortic aneurysm repair, assessing renal perfusion is critical, as the surgery may involve clamping the aorta, risking renal ischemia. Reduced urine output or elevated creatinine indicates renal compromise. Electrolyte imbalance, coping, and infection are secondary concerns.
The nurse is planning a staff development program related to infection control. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A?
- A. Gowning when entering a client's room.
- B. Wearing a mask when providing care.
- C. Assigning the client to a private room.
- D. Wearing gloves when giving direct care.
Correct Answer: D
Rationale: Hepatitis A is fecal-oral transmitted, so gloves (D) are essential during direct care to prevent contact with contaminated materials. Gowns (A), masks (B), and private rooms (C) are not required.
Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following?
- A. Signs of skin pressure in the groin area.
- B. Evidence of decreased breath sounds.
- C. Skin breakdown behind the heel.
- D. Urine retention.
Correct Answer: A
Rationale: The Thomas splint can cause pressure in the groin, requiring regular skin assessments to prevent breakdown.