Nokea
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medical health insurance claims
- C. Physical assessment findings
- D. Medications taken prior to admission
Correct Answer: C
Rationale: Physical assessment findings like mobility or pain are critical for a physical therapist to develop a tailored plan. Family history, insurance, or past medications are less relevant.
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A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication in the morning.
- B. I might lose weight while taking this medication.
- C. I need to avoid tyramine-rich foods.
- D. I can expect my mood to improve right away.
Correct Answer: A
Rationale: Fluoxetine is taken in the morning to avoid insomnia, showing understanding. Weight changes vary, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is reinforcing teaching with a client who has a new prescription for montelukast. Which of the following statements should the nurse include?
- A. You should take this medication in the evening.
- B. You might experience weight gain while taking this medication.
- C. You need to limit your fluid intake while taking this medication.
- D. You can take this medication with an antacid.
Correct Answer: A
Rationale: Montelukast is taken in the evening for asthma control. Weight gain, fluid limits, or antacids aren't significant concerns.
A nurse is caring for a client who is postoperative following a femoral-popliteal bypass. Which of the following actions should the nurse take?
- A. Check the client's pedal pulses every 2 hr.
- B. Instruct the client to keep the affected leg in a dependent position.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to cross their legs when seated.
Correct Answer: A
Rationale: Checking pedal pulses assesses circulation, critical post-bypass. Dependent positioning risks swelling, warm compresses aren't standard, and leg crossing impairs flow.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take this medication on an empty stomach.
- B. You might experience a metallic taste in your mouth.
- C. You should stop taking this medication if you feel shaky.
- D. You need to limit your protein intake while taking this medication.
Correct Answer: B
Rationale: Metformin can cause a metallic taste, a common side effect to anticipate. It's taken with meals, shakiness requires glucose, and protein limits aren't needed.
A nurse is caring for a client who is receiving IV vancomycin. Which of the following actions should the nurse take?
- A. Infuse the medication over 30 min.
- B. Monitor the client for tinnitus.
- C. Administer the medication with an antihistamine.
- D. Check the client's blood pressure every 4 hr.
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, so monitoring for tinnitus is essential. It's infused over 60-90 minutes, antihistamines aren't needed, and blood pressure checks aren't specific to vancomycin.