Nokea
A nurse is caring for a client who has a new prescription for lorazepam. For which of the following adverse effects should the nurse monitor?
- A. Urinary retention
- B. Dizziness
- C. Decreased appetite
- D. Hypertension
Correct Answer: B
Rationale: Rationale: The correct answer is B, dizziness, because lorazepam is a benzodiazepine that can cause central nervous system depression, leading to dizziness as a common adverse effect. Urinary retention (A) is not a common side effect of lorazepam. Decreased appetite (C) is not typically associated with lorazepam use. Hypertension (D) is not a common adverse effect of lorazepam. It is important to monitor for dizziness as it can affect the client's safety and mobility.
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A nurse is reinforcing discharge teaching with a client who has a prescription for rifampin for the treatment of tuberculosis (TB). Which of the following instructions should the nurse include in the teaching?
- A. Take the medication on an empty stomach.
- B. Discontinue the medication if your saliva turns orange.
- C. Return for another TB skin test in 3 months.
- D. You will need to take this medication for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Take the medication on an empty stomach. Rifampin is best absorbed when taken on an empty stomach, usually 1 hour before or 2 hours after meals. This maximizes its effectiveness in treating TB. Choice B is incorrect because discoloration of body fluids (including saliva) is a known side effect of rifampin and does not indicate the need to discontinue the medication. Choice C is incorrect because the client should not return for another TB skin test in 3 months unless specifically instructed by the healthcare provider. Choice D is incorrect because treatment for TB usually lasts for several months, not just 1 week.
A nurse in an influenza clinic is collecting data from four clients. Which of the following clients should the nurse identify as having a contraindication for receiving the live attenuated form of the influenza vaccine?
- A. An adolescent who received a new tattoo last week
- B. A client is at 27 weeks of gestation
- C. A client who is about to travel to a different country
- D. A school-age child who has rhinitis
Correct Answer: B
Rationale: The correct answer is B - A client at 27 weeks of gestation. Pregnant individuals are contraindicated to receive live attenuated influenza vaccine due to theoretical risk to the fetus. This is because live vaccines are not recommended during pregnancy. Choice A is incorrect as a recent tattoo does not contraindicate the vaccine. Choice C is incorrect as travel plans do not affect the decision to administer the vaccine. Choice D is incorrect as rhinitis is not a contraindication.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone to treat rheumatoid arthritis. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I should watch for weight loss.
- B. I should increase the sodium in my diet.
- C. I will take this medication on an empty stomach.
- D. I will report a sore throat to my provider.
Correct Answer: D
Rationale: The correct answer is D: "I will report a sore throat to my provider." This is the correct answer because prednisone can suppress the immune system, increasing the risk of infections like thrush or sore throat. Reporting these symptoms promptly is crucial to prevent complications.
Choice A is incorrect because prednisone can actually cause weight gain. Choice B is incorrect because prednisone can lead to fluid retention, so increasing sodium intake is not recommended. Choice C is incorrect because prednisone should be taken with food to reduce stomach upset.
A nurse is collecting data from a client who has been taking methimazole for 2 months for the treatment of a thyroid imbalance. Which of the following findings indicates that the medication is effective?
- A. Weight gain
- B. Decreased menstrual flow
- C. Clear breath sounds
- D. Increased libido
Correct Answer: A
Rationale: The correct answer is A: Weight gain. Methimazole is used to treat hyperthyroidism, which often causes weight loss due to increased metabolism. If the medication is effective, the client's thyroid hormone levels should normalize, leading to a potential reversal of weight loss and even weight gain. Decreased menstrual flow (B) and increased libido (D) are not direct indicators of methimazole effectiveness. Clear breath sounds (C) could indicate improved respiratory status but are not specific to thyroid function.
Nurses' Notes
0800:
Client reports frequent cough, wheezing, and tightness of chest. Bilateral breath sounds with scattered inspiratory and expiratory wheezes.
1000:
Reinforced teaching about newly prescribed medications.
Click to highlight the instructions the nurse should reinforce to the client.
- A. Take your albuterol when you are having difficulty breathing.
- B. Hold your breath for 20 seconds when taking your albuterol.
- C. Take the salmeterol 5 minutes before the albuterol when you need both medications.
- D. Take the salmeterol 2 times each day.
- E. Rinse out your mouth after taking the fluticasone.
- F. Take the fluticasone as needed for an asthma attack.
Correct Answer: A,D,E
Rationale: Sure, here is a detailed explanation for each choice:
A: Taking albuterol during difficulty breathing helps relieve symptoms promptly.
D: Salmeterol should be taken twice daily for optimal effectiveness.
E: Rinsing mouth after fluticasone reduces the risk of oral thrush.
Incorrect choices:
B: Holding breath doesn't affect albuterol efficacy.
C: Timing salmeterol before albuterol isn't necessary.
F: Fluticasone is a controller, not a rescue inhaler.