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A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings should the nurse report to the provider?
- A. The client reports a headache.
- B. The client's pupils are unequal.
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/85 mm Hg.
Correct Answer: B
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration, requiring reporting. Headache, minimal drainage, and normal BP are less urgent.
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A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. The client's blood glucose is 120 mg/dL.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's weight increased by 0.5 kg overnight.
- D. The client reports mild discomfort at the IV site.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, possibly catheter-related, requiring reporting. Normal glucose, slight weight gain, and mild discomfort are less urgent.
A nurse is caring for a client who is postoperative following a lumbar puncture. Which of the following actions should the nurse take?
- A. Encourage the client to lie flat for 2 to 4 hr.
- B. Instruct the client to limit fluid intake.
- C. Apply a warm compress to the puncture site.
- D. Monitor the client's temperature every 8 hr.
Correct Answer: A
Rationale: Lying flat prevents post-lumbar puncture headache by reducing CSF leakage. Fluid restriction is unnecessary, warm compresses aren't standard, and temperature checks are more frequent if infection is suspected.
A nurse is reinforcing teaching with a client who has a new prescription for bupropion. Which of the following statements should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods while taking this medication.
- D. You can expect immediate improvement in your mood.
Correct Answer: B
Rationale: Bupropion can cause dry mouth, a common side effect. It's taken in the morning, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is reinforcing teaching with a client who has a new prescription for lisinopril. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I might need to check my blood pressure regularly.
- C. I can stop taking this medication if I feel better.
- D. I should avoid getting up quickly from sitting.
Correct Answer: B,D
Rationale: Lisinopril requires blood pressure monitoring and caution with position changes due to hypotension risk. Food isn't required, and stopping abruptly is unsafe.
A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication in the morning.
- B. I might need to have my liver function checked.
- C. I can stop taking this medication if my cholesterol improves.
- D. I should avoid drinking alcohol while taking this medication.
Correct Answer: B,D
Rationale: Atorvastatin requires liver monitoring due to hepatotoxicity risk and alcohol avoidance to reduce liver strain. It's taken at night, and stopping needs provider input.