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A nurse in an assisted living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?
- A. Open the fireplace dampers in the day room.
- B. Cover the electrical outlets with wet towels.
- C. Move clients to a room above ground with few windows.
- D. Turn on fans in the facility to circulate air.
Correct Answer: C
Rationale: Moving clients to an aboveground room with few windows minimizes exposure to chemical contaminants. Opening dampers or turning on fans could introduce contaminants, and covering outlets with wet towels is ineffective.
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A nurse is reinforcing teaching with a client who has a new prescription for bupropion. Which of the following statements should the nurse include?
- A. Take this medication at bedtime.
- B. You might have dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods.
- D. You can expect immediate mood improvement.
Correct Answer: B
Rationale: Bupropion can cause dry mouth, a side effect to monitor. It's taken in the morning, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is caring for a client who is receiving IV heparin. Which of the following actions should the nurse take?
- A. Monitor the client's prothrombin time (PT).
- B. Administer the heparin via IV push.
- C. Check the client's activated partial thromboplastin time (aPTT).
- D. Instruct the client to increase vitamin K intake.
Correct Answer: C
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation. PT is for warfarin, heparin infuses slowly, and vitamin K counteracts it.
A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent infection?
- A. Change the IV tubing every 24 hr.
- B. Clean the IV insertion site with alcohol before insertion.
- C. Monitor the IV site for redness or swelling.
- D. Use a new IV catheter for each attempt.
Correct Answer: C
Rationale: Monitoring for redness or swelling detects infection early. Tubing changes are every 72-96 hours, alcohol is standard, and new catheters are used per attempt.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take?
- A. Encourage the client to eat raw fruits and vegetables.
- B. Monitor the client's white blood cell count.
- C. Administer an antipyretic every 4 hr.
- D. Instruct the client to avoid handwashing.
Correct Answer: B
Rationale: Monitoring WBC count detects neutropenia, critical for infection prevention. Raw produce risks infection, antipyretics aren't routine, and handwashing is essential.
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.