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A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse report to the provider?
- A. The client's oxygen saturation is 95%.
- B. The client's cuff pressure is 35 cm H2O.
- C. The client's respiratory rate is 16 breaths/min.
- D. The client's temperature is 37.1°C (98.8°F).
Correct Answer: B
Rationale: A cuff pressure of 35 cm H2O (above 20-30 cm H2O) risks tracheal damage, requiring reporting. Normal saturation, respiratory rate, and temperature are unremarkable.
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A nurse is reinforcing teaching with a client who has a new prescription for doxycycline. Which of the following statements should the nurse include?
- A. You should take this medication on an empty stomach.
- B. You might experience sensitivity to sunlight.
- C. You need to refrigerate this medication.
- D. You can take this medication with an antacid.
Correct Answer: B
Rationale: Doxycycline increases photosensitivity, requiring sun protection. It's taken with food to avoid upset, doesn't need refrigeration, and antacids reduce absorption.
A nurse is reinforcing teaching with a client who has a new prescription for furosemide. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You might need to eat more potassium-rich foods.
- C. You need to limit your fluid intake.
- D. You should stop taking this medication if you feel dizzy.
Correct Answer: B
Rationale: Furosemide causes potassium loss, so increasing intake helps prevent hypokalemia. It's taken in the morning, fluid limits aren't standard, and dizziness needs evaluation.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take to prevent infection?
- A. Encourage the client to avoid fresh fruits and vegetables.
- B. Administer prophylactic antibiotics daily.
- C. Monitor the client's white blood cell count regularly.
- D. Instruct the client to avoid crowded places.
Correct Answer: C
Rationale: Monitoring WBC counts detects neutropenia early, guiding infection prevention. Fresh produce is safe if washed, antibiotics aren't routine, and avoiding crowds is secondary.
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. Take this medication at bedtime.
- B. You might have dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods.
- D. You can expect immediate mood improvement.
Correct Answer: B
Rationale: Bupropion can cause dry mouth, a side effect to monitor. It's taken in the morning, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
- A. Tell the client she should discuss this decision with her family.
- B. Support the client's decision to stop the treatment.
- C. Discuss alternative treatment methods with the client.
- D. Ask the facility chaplain to visit the client.
Correct Answer: B
Rationale: Supporting the client's decision respects autonomy, a core ethical principle. Discussing with family, alternatives, or involving a chaplain are secondary to honoring the client's choice.