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A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?
- A. I'm going to take your heart rate.
- B. I need to give you diphenhydramine.
- C. Are you having difficulty breathing?
- D. Do you have any allergies to medications?
Correct Answer: C
Rationale: Asking about difficulty breathing is the priority as it assesses for anaphylaxis, a life-threatening allergic reaction to penicillin, requiring immediate intervention.
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A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?
- A. 3 oz chicken breast
- B. 3 oz canned tuna
- C. 3 oz pork roast
- D. 3 oz ground beef
Correct Answer: D
Rationale: Ground beef has the highest iron content (about 2.7 mg/3 oz) among these options, making it best for iron-deficiency anemia.
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Limit the client's physical activity until bowel continence is achieved.
- B. Assist the client to the restroom 30 min after meals.
- C. Instruct the client to limit their intake of high-fiber foods.
- D. Limit the client's fluid intake to 1500 mL/day
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.
A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
- A. Leave the television on in the client's room
- B. Raise all four side rails while the client is in bed.
- C. Move the overbed table away from the bed.
- D. Apply a motion sensor mat to the client's bed
Correct Answer: D
Rationale: A motion sensor mat alerts staff to movement, reducing fall risk in dementia clients. TV can agitate, four rails are a restraint, and moving the table doesn't directly prevent falls.
A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?
- A. Refill the prescription every 12 months.
- B. Take a second tablet after 5 min for unrelieved chest pain.
- C. Swallow the tablet whole with a glass of water.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Taking a second dose after 5 minutes for unrelieved pain is standard protocol for nitroglycerin, which is taken sublingually, not swallowed, and stored at room temperature, refilled every 6 months.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Rhinitis
- B. Metallic taste
- C. Ringing in ears
- D. Agitation
- E. Weight gain
- F. Dry cough
- G. Blurred vision
Correct Answer: C
Rationale: Ringing in ears (tinnitus) is a sign of furosemide ototoxicity; rhinitis and metallic taste aren't typical.