Nokea
A client with severe hypertension is receiving Capoten (captopril). The nurse should instruct the client to report which of the following to the doctor?
- A. Coughing
- B. Drowsiness
- C. Frequent urination
- D. Hunger
Correct Answer: A
Rationale: A persistent cough is a common side effect of ACE inhibitors like captopril, potentially requiring a change in medication.
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The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?
- A. I need to have the entire house treated by pest control to ensure the bed bugs are gone.
- B. I should concentrate on alleviating scratching as it can cause further complications.
- C. My other family members and pets are at risk of bed bug bites.
- D. This must have happened because I did not wash the bed sheets this week.
Correct Answer: D
Rationale: Bed bug infestations are not caused by unwashed sheets but by exposure to infested environments. This misconception indicates a need for further teaching about bed bug transmission and prevention.
The nurse is caring for a client who is experiencing status epilepticus and does not have a peripheral venous access device. Which of the following actions should the nurse take first?
- A. Administer rectal diazepam.
- B. Transport the client for a CT scan.
- C. Obtain a blood specimen for complete blood count.
- D. Check the client for neck stiffness and Brudzinski sign.
Correct Answer: A
Rationale: Rectal diazepam is a first-line treatment for status epilepticus when IV access is unavailable, as it rapidly terminates seizures to prevent brain damage.
The nurse prepares to reinforce teaching for a client with latent tuberculosis who is prescribed oral isoniazid. Which instructions should the nurse include? Select all that apply.
- A. Avoid drinking alcohol
- B. Expect body fluids to change color to red
- C. Report yellowing of skin or sclera
- D. Report numbness and tingling of extremities
- E. Take with aluminum hydroxide to prevent gastric irritation
Correct Answer: A,C,D
Rationale: Avoiding alcohol (A), reporting jaundice (C), and reporting neuropathy (D) address isoniazid's risks of hepatotoxicity and peripheral neuropathy.
During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?
- A. leave a book about relaxation techniques
- B. write out a daily exercise routine for them to assist the client to do
- C. list actions to improve the client's daily nutritional intake
- D. suggest communication strategies
Correct Answer: D
Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.
The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?
- A. Client on chemotherapy who started antibiotics today for cellulitis of the leg
- B. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours
- C. Client with diabetes who has nausea, abdominal pain, and vomiting
- D. Client with ulcerative colitis and diarrhea who has developed fever and vomiting
Correct Answer: B
Rationale: The client with resolved asthma exacerbation, not requiring oxygen or nebulizers for 12 hours, is stable and safe for discharge, unlike the others with active complications.