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A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?
- A. Constipation
- B. Blurred vision
- C. Fever
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.
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A nurse is caring for a client who is receiving radiation therapy. Which of the following side effects should the nurse monitor for?
- A. Fatigue
- B. Hair loss
- C. Nausea
- D. Dry mouth
Correct Answer: D
Rationale: The correct answer is D, dry mouth. Dry mouth is a common side effect of radiation therapy due to damage to the salivary glands. It is essential for the nurse to monitor for this condition as it can lead to oral health issues and discomfort. Fatigue (choice A) is a common side effect of radiation therapy, but in this case, dry mouth is a more specific side effect to monitor for. Hair loss (choice B) is more commonly associated with chemotherapy rather than radiation therapy. Nausea (choice C) is also a common side effect of radiation therapy, but dry mouth is a more direct effect of the treatment that the nurse should focus on monitoring.
A healthcare professional is assessing a client who has chronic kidney disease. Which of the following findings is an indication for hemodialysis?
- A. BUN 16 mg/dL
- B. Serum magnesium 1.8 mg/dL
- C. Serum phosphorus 4.0 mg/dL
- D. Glomerular filtration rate of 14 mL/min
Correct Answer: D
Rationale: A glomerular filtration rate of 14 mL/min indicates severe kidney impairment and the need for hemodialysis. The other choices, such as BUN 16 mg/dL, serum magnesium 1.8 mg/dL, and serum phosphorus 4.0 mg/dL, are within normal ranges and do not directly indicate the need for hemodialysis in chronic kidney disease.
What is the best way to monitor fluid balance in a patient with kidney disease?
- A. Monitor daily weight
- B. Monitor input and output
- C. Check for edema
- D. Check urine output
Correct Answer: A
Rationale: The correct answer is to monitor daily weight. This method is the most accurate way to assess fluid balance in patients with kidney disease. Daily weight monitoring can detect even small changes in fluid balance, such as fluid retention or loss, which may not be evident through other methods. Monitoring input and output (choice B) is also important but may not provide a complete picture of fluid balance as it doesn't consider factors like insensible losses. Checking for edema (choice C) is a sign of fluid retention but may not always be present or may be difficult to assess accurately. Checking urine output (choice D) is important but may not reflect the overall fluid balance status of the patient.
A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water before each feeding.
- B. Check for gastric residuals every 4 hours.
- C. Elevate the head of the bed to 45 degrees during feedings.
- D. Place the client in the left lateral position during feedings.
Correct Answer: C
Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.
A client who has a new diagnosis of hypertension is being taught about dietary modifications by a nurse. Which of the following instructions should the nurse include?
- A. Limit fluid intake to 2 liters per day.
- B. Increase your intake of whole grains.
- C. Eat 3 large meals daily.
- D. Consume foods high in potassium.
Correct Answer: B
Rationale: The correct answer is B: 'Increase your intake of whole grains.' Whole grains are beneficial for individuals with hypertension as they can help promote heart health. Whole grains are high in fiber, which can help lower blood pressure. Option A is incorrect as fluid intake should be adequate but not restricted to 2 liters per day. Option C is incorrect as it is recommended to have smaller, more frequent meals rather than 3 large meals to help manage hypertension. Option D is incorrect; although foods high in potassium can be beneficial for hypertension, the most appropriate dietary modification to include in this scenario is increasing whole grain intake.