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A nurse is caring for a client who is postoperative following a craniotomy. Which of the following actions should the nurse take?
- A. Position the client flat in bed.
- B. Monitor the client's neurological status every 2 hr.
- C. Encourage the client to cough vigorously.
- D. Administer a stool softener as needed.
Correct Answer: B
Rationale: Frequent neurological checks detect complications like increased intracranial pressure early. Flat positioning risks pressure, vigorous coughing is avoided, and stool softeners prevent straining.
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A nurse is reinforcing teaching with a client who has a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication on an empty stomach.
- B. I might need to check my blood sugar more often.
- C. I can stop taking this medication if I lose weight.
- D. I should avoid drinking alcohol while taking this medication.
Correct Answer: B,D
Rationale: Metformin requires frequent glucose monitoring and alcohol avoidance to prevent lactic acidosis. It's taken with food, and stopping needs provider approval.
A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.
- A. Discarding worksheets containing client information in a wastebasket
- B. Writing a client's diagnosis on the message board in the client's room
- C. Giving change of shift report to a nurse outside the client's room
- D. Discussing a client's prognosis with an assistive personnel who is caring for the client
Correct Answer: C
Rationale: Giving a shift report in a private setting prevents unauthorized individuals from overhearing, protecting confidentiality. Discarding worksheets improperly, writing diagnoses publicly, or discussing prognosis openly risks breaches.
A nurse is reinforcing teaching with a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?
- A. Take this medication every morning.
- B. You might experience a rapid heartbeat.
- C. You need to rinse your mouth after using this medication.
- D. You should use this medication to prevent asthma attacks.
Correct Answer: B
Rationale: Albuterol can cause tachycardia, a side effect to anticipate. It's used as needed, not daily, mouth rinsing is for steroids, and it treats, not prevents, attacks.
A nurse is reinforcing teaching with a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?
- A. You can take this medication with or without food.
- B. You should avoid eating citrus fruits.
- C. You need to increase your intake of calcium.
- D. You should take this medication at bedtime.
Correct Answer: A
Rationale: Clopidogrel's administration is flexible with food, enhancing compliance. Citrus, calcium, or bedtime dosing aren't specific requirements.
A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?
- A. Obtain the child's dietary history.
- B. Offer the child nutritious snacks between meals.
- C. Encourage the family to be with the child during mealtimes.
- D. Instruct the family to praise the child when they eat.
Correct Answer: A
Rationale: Obtaining a dietary history identifies patterns and causes of poor intake, guiding subsequent interventions like snacks or family involvement.