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A nurse is caring for a client who is receiving IV vancomycin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild itching.
- B. The client's urine output is 40 mL/hr.
- C. The client's infusion site is red and warm.
- D. The client's blood pressure is 130/80 mm Hg.
Correct Answer: C
Rationale: Redness and warmth at the infusion site suggest phlebitis or infiltration, requiring reporting. Itching, normal urine output, and stable BP are less concerning.
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A nurse is reinforcing teaching with a client who has a new prescription for amoxicillin. Which of the following instructions should the nurse include?
- A. Take this medication with an antacid to prevent stomach upset.
- B. You might experience diarrhea while taking this medication.
- C. You need to refrigerate this medication.
- D. You should stop taking this medication if you feel better.
Correct Answer: B
Rationale: Amoxicillin can cause diarrhea, a common side effect. Antacids aren't needed, refrigeration depends on form, and stopping early risks resistance.
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 is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure.
- A. Tingling of the scalp
- B. Voice alteration
- C. Neck pain
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect of ECT, often resolving post-treatment. Tingling, voice changes, or neck pain are not typically associated with ECT.
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following findings should the nurse report to the provider?
- A. The client reports mild discomfort at the IV site.
- B. The client's heart rate is irregular.
- C. The client's urine output is 50 mL/hr.
- D. The client's blood pressure is 118/76 mm Hg.
Correct Answer: B
Rationale: An irregular heart rate suggests hyperkalemia or arrhythmia, requiring reporting. Mild discomfort, normal urine output, and stable BP are less concerning.
A nurse is reinforcing teaching with a client who has a new prescription for valsartan. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a high-potassium meal.
- B. I might need to check my blood pressure regularly.
- C. I need to avoid exercise.
- D. I can stop taking this medication if I feel better.
Correct Answer: B
Rationale: Valsartan requires blood pressure monitoring, showing understanding. Potassium meals, exercise avoidance, and stopping abruptly aren't appropriate.