Nokea
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?
- A. The client reports mild pain at the surgical site.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's knee is slightly swollen.
- D. The client can flex the knee 90 degrees.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, requiring reporting. Mild pain, slight swelling, and good flexion are expected post-arthroplasty.
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A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?
- A. The headaches should decrease as you get used to the medication.
- B. Swallow the tablet whole to minimize your headaches.
- C. You should take the medication on an empty stomach to prevent a headache.
- D. You can discontinue the medication until the headache goes away.
Correct Answer: A
Rationale: Headaches from isosorbide dinitrate often diminish over time as the body adjusts. Swallowing whole, taking on an empty stomach, or discontinuing aren't recommended.
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.
A nurse is reinforcing teaching with a client who has a new prescription for valsartan. Which of the following statements should the nurse include?
- A. You should take this medication with a high-potassium meal.
- B. You might experience a cough while taking this medication.
- C. You need to avoid exercise while taking this medication.
- D. You can take this medication at any time of day.
Correct Answer: D
Rationale: Valsartan's timing is flexible, aiding compliance. Potassium meals, cough (less common than with ACE inhibitors), or exercise limits aren't primary concerns.
The nurse is reviewing the medical record of a client who has a new prescription for zolpidem. Which of the following findings should the nurse identify as a potential contraindication for this medication?
- A. History of migraines
- B. Current use of sertraline
- C. Seasonal allergies
- D. History of sleepwalking
Correct Answer: D
Rationale: Zolpidem can exacerbate sleepwalking, making it a contraindication. Migraines, sertraline, or allergies don't pose significant risks with zolpidem.
A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?
- A. Observe the client during and after meals.
- B. Suggest that the client assist with meal planning.
- C. Instruct the client about effective coping strategies.
- D. Refer the client to a support group for clients who have eating disorders.
Correct Answer: A
Rationale: Observing during and after meals monitors for purging behaviors, a priority for safety in bulimia. Meal planning, coping strategies, and support groups follow after ensuring immediate safety.