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A nurse is assessing a client who is taking an osmotic laxative. Which of the following findings should the nurse identify as an indication of fluid volume deficit?
- A. Nausea
- B. Weight gain
- C. Headache
- D. Oliguria
Correct Answer: D
Rationale: The correct answer is D: Oliguria. Osmotic laxatives, such as lactulose or polyethylene glycol, work by drawing water into the colon to soften the stool. If a client on osmotic laxatives is experiencing oliguria (decreased urine output), it can be a sign of fluid volume deficit due to the body trying to conserve water. Nausea (A) is a common side effect of osmotic laxatives but not a specific indicator of fluid volume deficit. Weight gain (B) is not associated with fluid volume deficit. Headache (C) can be caused by various factors and is not a specific sign of fluid volume deficit.
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A nurse is teaching a client who has angina a new prescription for sublingual nitroglycerin tablets. Which of the following instructions should the nurse include in the teaching?
- A. Discard any tablets you do not use every 6 months.
- B. Take one tablet each morning 30 minutes prior to eating.
- C. Keep the tablets at room temperature in their original glass bottle.
- D. Place the tablet between your cheek and gum to dissolve.
Correct Answer: C
Rationale: The correct answer is C: Keep the tablets at room temperature in their original glass bottle. Nitroglycerin tablets are sensitive to light, moisture, and heat. Storing them in their original glass bottle at room temperature helps maintain their potency. Discarding unused tablets every 6 months (choice A) is not necessary as long as they are stored properly. Taking a tablet each morning (choice B) is not recommended as nitroglycerin is usually taken as needed for angina attacks. Placing the tablet between cheek and gum (choice D) is not the correct administration route for sublingual nitroglycerin, as it should be placed under the tongue for rapid absorption.
A nurse is planning teaching for a client who is trying to quit smoking. Which of the following instructions about nicotine replacement options should the nurse include?
- A. Change the nicotine patch every other day.
- B. Do not drink beverages while sucking on a nicotine lozenge.
- C. Chew nicotine gum for 10 min before spitting it out.
- D. Administer 2 sprays of nicotine nasal spray in each nostril with each dose.
Correct Answer: B
Rationale: The correct answer is B: Do not drink beverages while sucking on a nicotine lozenge. This instruction is important because beverages can interfere with the absorption of nicotine from the lozenge. Nicotine replacement therapy works best when the nicotine is absorbed properly, so avoiding beverages while using the lozenge will help ensure its effectiveness. Changing the nicotine patch every other day (choice A) is incorrect as patches are typically changed daily. Chewing nicotine gum for 10 minutes before spitting it out (choice C) is incorrect as the gum should be chewed until a tingling sensation is felt, then parked between the cheek and gum. Administering 2 sprays of nicotine nasal spray in each nostril with each dose (choice D) is incorrect as the dosage is usually one spray in each nostril.
A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissue surrounding the insertion site. Which of the following actions should the nurse take?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct action is to elevate the extremity. Elevating the extremity above the level of the heart helps to reduce swelling and prevent further fluid infiltration into the surrounding tissue. This promotes proper circulation and limits potential complications. Flushing the IV catheter (choice A) would not address the infiltration issue. Applying pressure to the IV site (choice B) could cause further damage to the tissue. Slowing the infusion rate (choice D) may not be sufficient to prevent further infiltration.
A nurse is teaching a guardian of a school-age child who has a new prescription for a fluticasone metered-dose inhaler. Which of the following information should the nurse include in the teaching? (SATA)
- A. Soak the inhaler in water after use.
- B. Have your child take one inhalation as needed for shortness of breath.
- C. Shake the device prior to administration.
- D. A spacer will make it easier to use the device.
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Shake the device prior to administration - Shaking the inhaler ensures proper mixing of the medication for effective delivery to the lungs.
D: A spacer will make it easier to use the device - A spacer helps improve medication delivery by ensuring more of the medication reaches the lungs rather than the mouth or throat.
E: - Additional information may include the importance of proper inhaler technique, how to clean the device, how to monitor for side effects, and when to seek medical help.
Incorrect Choices:
A: Soak the inhaler in water after use - Soaking the inhaler in water can damage the device and affect the medication's effectiveness.
B: Have your child take one inhalation as needed for shortness of breath - The prescription likely specifies a specific dosing regimen that should be followed, rather than using the inhaler as needed.
Which of the following statements should the nurse include when teaching the client about the prescribed medication?
- A. The medication can cause nausea, so take with a meal.
- B. You can experience vivid nightmares.
- C. You may notice your urine becomes lighter in color.
- D. Consumption of a high protein meal can reduce the effectiveness of the medication.
- E. You may initially notice an increase in involuntary movements.
Correct Answer: A
Rationale: The correct answer is A because taking the medication with a meal can help reduce nausea. This statement is important to ensure client compliance and improve medication tolerance. Choice B is incorrect as vivid nightmares are not a common side effect of the medication. Choice C is incorrect as urine color change is not relevant to this medication. Choice D is incorrect as high protein meals do not affect medication effectiveness. Choice E is incorrect as an increase in involuntary movements is not expected with this medication.