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A nurse is caring for a client who is receiving IV chemotherapy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild fatigue.
- B. The client's IV site is cool and swollen.
- C. The client's urine output is 200 mL over 4 hr.
- D. The client's temperature is 37.2°C (99°F).
Correct Answer: B
Rationale: A cool, swollen IV site suggests extravasation, a chemotherapy emergency requiring reporting. Fatigue, normal urine output, and mild fever are less urgent.
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A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for lithium. Which of the following instructions should the nurse include in the teaching?
- A. Increase intake of foods high in potassium.
- B. Maintain a consistent sodium intake.
- C. Limit daily exercise to 30 min.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Consistent sodium intake prevents lithium toxicity or reduced efficacy. Potassium, exercise limits, or empty stomach administration aren't necessary.
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 teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- A. Keep the airbag on if the car seat is in the front seat.
- B. Position the car seat at a 90° angle.
- C. Put a small cushion under the newborn's head for support.
- D. Place the shoulder harnesses at the level of the infant's shoulders.
Correct Answer: D
Rationale: Shoulder harnesses at shoulder level ensure a secure fit, enhancing safety. Airbags should be off for front-seat car seats, the angle should be 45°, and cushions can disrupt proper positioning.
A nurse is reinforcing teaching with a client who has a new prescription for lorazepam. Which of the following instructions should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience dizziness while taking this medication.
- C. You need to increase your fluid intake while taking this medication.
- D. You can take this medication with an antacid.
Correct Answer: B
Rationale: Lorazepam can cause dizziness, a key safety concern. Timing is flexible, fluid increase isn't needed, and antacids don't interact significantly.
A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Justice
- B. Autonomy
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity involves truthful communication. By honestly discussing medication side effects, the nurse upholds this principle, supporting informed decision-making.