Nokea
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?
- A. Notify the charge nurse.
- B. Check the client's vital signs.
- C. Fill out an occurrence report according to institutional policy.
- D. Document an objective description of what has happened in the client's chart.
Correct Answer: B
Rationale: Checking the client's vital signs is the priority to assess for adverse effects, such as hypotension, ensuring immediate safety.
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A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?
- A. Abduction.
- B. Internal rotation.
- C. External rotation.
- D. Adduction.
Correct Answer: A
Rationale: Abduction prevents hip dislocation by keeping the leg away from the midline, maintaining joint stability post-arthroplasty.
A nurse is reinforcing dietary instructions with a client who has chronic kidney disease. Which of the following information should the nurse include?
- A. Maintain a low carbohydrate diet.
- B. Eliminate ingestion of foods high in protein.
- C. Increase intake of sodium-containing food.
- D. Reduce intake of foods high in potassium.
Correct Answer: D
Rationale: Reducing foods high in potassium is crucial in CKD to prevent hyperkalemia due to impaired renal potassium excretion.
A nurse is reinforcing teaching with a client who has a new prescription for phenazopyridine. The nurse should reinforce to the client to expect which of the following while taking this medication?
- A. Lethargy.
- B. Reddish-orange urine.
- C. Burning during urination.
- D. Visual disturbances.
Correct Answer: B
Rationale: Reddish-orange urine is a common and expected side effect of phenazopyridine, which is harmless but can stain clothing.
A nurse is reinforcing discharge instructions with a client who has a new prescription for phenazopyridine hydrochloride. Which of the following statements should the nurse include in the instructions?
- A. Phenazopyridine hydrochloride turns the urine purple.
- B. Administer phenazopyridine hydrochloride before meals.
- C. Yellowing of the sclera is an expected effect of phenazopyridine hydrochloride.
- D. Phenazopyridine hydrochloride works as a urinary tract analgesic.
Correct Answer: D
Rationale: Phenazopyridine hydrochloride works as a urinary tract analgesic, relieving pain, burning, and discomfort caused by urinary tract irritation.
A nurse is reinforcing teaching with a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of the following client statements indicates the need for further teaching?
- A. I should avoid taking bubble baths.
- B. I will need to empty my bladder after having sexual intercourse.
- C. I will need to wipe my perineal area from back to front after urination.
- D. I need to drink at least 8 full glasses of liquid each day.
Correct Answer: C
Rationale: Wiping from back to front can transfer bacteria to the urethra, increasing UTI risk, indicating a need for further teaching on proper hygiene.