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A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate within 24 hr.
- B. Instruct the client to avoid coughing.
- C. Apply a cold pack to the incision site.
- D. Administer a laxative every 2 hr.
Correct Answer: A
Rationale: Ambulation within 24 hours prevents thromboembolism and aids recovery. Coughing supports lung function, cold packs aren't standard, and laxatives aren't given that frequently.
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A nurse is reinforcing teaching with a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?
- A. Take this medication with food to prevent stomach upset.
- B. You might experience bruising more easily.
- C. You need to avoid eating citrus fruits.
- D. You should take this medication at bedtime.
Correct Answer: B
Rationale: Clopidogrel increases bleeding risk, leading to easy bruising. Food isn't required, citrus isn't restricted, and timing is flexible.
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching?
- A. You might experience weight loss while taking this medication.
- B. You should expect to have increased energy within a few days.
- C. You might feel drowsy, so avoid driving until you know how this medication affects you.
- D. You can stop taking this medication as soon as your symptoms improve.
Correct Answer: C
Rationale: Amitriptyline can cause drowsiness, so avoiding driving is prudent. Weight gain, not loss, is common, effects take weeks, and abrupt stopping risks relapse.
A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings should the nurse monitor for?
- A. Hypotension
- B. Hyperglycemia
- C. Hypocalcemia
- D. Bradycardia
Correct Answer: C
Rationale: Thyroidectomy risks hypoparathyroidism, leading to hypocalcemia, which can cause tetany or seizures. Hypotension, hyperglycemia, or bradycardia aren't primary concerns.
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following actions should the nurse take?
- A. Monitor the client's cardiac rhythm.
- B. Administer the IV fluids through a large-gauge needle.
- C. Check the client's magnesium levels every 8 hr.
- D. Instruct the client to reduce sodium intake.
Correct Answer: A
Rationale: Potassium chloride can cause arrhythmias, so cardiac monitoring is essential. Needle size varies, magnesium isn't routinely checked, and sodium restriction isn't specific.
A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
- A. Limit the client's social interactions.
- B. Encourage the client to be assertive.
- C. Assume responsibility for making the client's decisions.
- D. Maintain a verbal no-harm contract with the client.
Correct Answer: B
Rationale: Encouraging assertiveness promotes independence, countering dependency tendencies. Limiting interactions or making decisions for the client reinforces dependence, and no-harm contracts are unrelated.