Nokea
A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?
- A. Blood glucose levels.
- B. Gallbladder studies.
- C. Liver function tests.
- D. Thyroid function studies.
Correct Answer: C
Rationale: Liver function tests are required for pyrazinamide due to its potential for hepatotoxicity, necessitating regular monitoring.
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A nurse is reinforcing teaching for a client who has rheumatoid arthritis and a new prescription for aspirin 650 mg orally every 6 hr. The nurse should instruct the client to monitor for which of the following adverse effects of aspirin therapy?
- A. Constipation.
- B. Blurred vision.
- C. Insomnia.
- D. Bleeding.
Correct Answer: D
Rationale: Bleeding is a well-known adverse effect of aspirin due to its inhibition of platelet aggregation, increasing the risk of gastrointestinal bleeding or bruising.
A nurse is contributing to the plan of care for an older adult client who has a WBC of 2000/mm³ after three rounds of chemotherapy. Which of the following interventions should the nurse include in the plan?
- A. Serve cooked fruit with meals.
- B. Report temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours.
- C. Place the client in a room with negative-pressure airflow.
- D. Instruct client to use an incentive spirometer every 4 hours.
Correct Answer: A
Rationale: Serving cooked fruit reduces infection risk by eliminating pathogens, appropriate for a client with low WBC counts.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)
- A. Monitor the puncture site for hematoma.
- B. Elevate the client's head of bed.
- C. Insert a urinary catheter.
- D. Encourage fluid intake.
- E. Apply a cervical collar to the client.
Correct Answer: A,D
Rationale: Monitoring the puncture site for hematoma and encouraging fluid intake are crucial to detect complications and replenish cerebrospinal fluid, reducing the risk of post-lumbar puncture headache.
A nurse in a clinic is caring for a client who has heart failure and is taking digoxin. Which of the following statements by the client indicates the client is experiencing digoxin toxicity?
- A. My tongue is red and beefy.
- B. I am constipated.
- C. My vision seems yellow.
- D. I am gaining weight.
Correct Answer: C
Rationale: Yellow vision (xanthopsia) is a classic symptom of digoxin toxicity, caused by its effects on the optic nerve.
A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 2 mL
Rationale: 4 mg ÷ 2 mg/mL = 2 mL. The nurse should administer 2 mL.