Nokea
A client with pneumonia is receiving oxygen therapy. The nurse notes cyanosis and a respiratory rate of 32 breaths/min. What should the nurse do first?
- A. Increase the oxygen flow rate.
- B. Notify the physician.
- C. Encourage coughing and deep breathing.
- D. Reposition the client.
Correct Answer: B
Rationale: Cyanosis and tachypnea indicate worsening hypoxia, requiring immediate physician notification to adjust treatment.
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A client with a history of peptic ulcer disease is prescribed misoprostol (Cytotec). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid antacids.
- C. Take the medication at bedtime.
- D. Stop the medication if diarrhea occurs.
Correct Answer: A
Rationale: Misoprostol should be taken with meals to reduce gastrointestinal upset and protect the stomach lining.
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.
A client with a history of renal calculi is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
- A. Increase fluid intake.
- B. Avoid dairy products.
- C. Take the medication with meals.
- D. Stop the medication if pain resolves.
Correct Answer: A
Rationale: Increased fluid intake prevents stone formation while taking allopurinol for uric acid stones.
A client with a history of depression is prescribed trazodone (Desyrel). The nurse should instruct the client to take the medication:
- A. In the morning to avoid sedation.
- B. At bedtime to promote sleep.
- C. With meals to enhance absorption.
- D. As needed for low mood.
Correct Answer: B
Rationale: Trazodone is sedating and should be taken at bedtime to promote sleep and manage depression.
A client diagnosed with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that what can trigger the pain?
- A. Infection or stress
- B. Hypoglycemia and fatigue
- C. Facial pressure or extreme temperature
- D. Excessive watering of the eyes or nasal stuffiness
Correct Answer: C
Rationale: The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating and drinking, and yawning. Symptoms can also be triggered by thermal stimuli such as a draft of cold air. The items listed in the other options do not trigger the spasm.