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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.
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A nurse is reinforcing teaching with a client who has a new prescription for metoprolol. Which of the following statements should the nurse include?
- A. You should take this medication with a high-fiber meal.
- B. You might experience fatigue while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You can stop taking this medication if your blood pressure is normal.
Correct Answer: B
Rationale: Metoprolol can cause fatigue, a common side effect to monitor. Fiber meals, caffeine avoidance, or stopping abruptly aren't recommended.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Which of the following actions should the nurse take?
- A. Infuse the blood over 6 hr.
- B. Check the client's temperature every 30 min.
- C. Administer the blood through a 22-gauge IV catheter.
- D. Flush the IV line with dextrose 5% in water before infusion.
Correct Answer: B
Rationale: Monitoring temperature every 30 minutes detects transfusion reactions early. Blood infuses over 2-4 hours, requires a large-gauge catheter, and saline, not dextrose, is used.
A nurse is caring for a client who is receiving continuous bladder irrigation following a TURP. Which of the following findings should the nurse report to the provider?
- A. The client reports bladder spasms.
- B. The irrigation fluid is slightly pink.
- C. The client's urine output is bright red with clots.
- D. The client's catheter is draining freely.
Correct Answer: C
Rationale: Bright red urine with clots indicates potential hemorrhage, requiring immediate reporting. Spasms and pink fluid are expected, and free drainage is normal.
A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz. of which of the following beverages contains the least amount of caffeine?
- A. Hot cocoa
- B. Cola soft drink
- C. Instant coffee
- D. Brewed green tea
Correct Answer: A
Rationale: Hot cocoa contains approximately 5 mg of caffeine per 240 mL, significantly less than cola soft drink (24-31 mg), instant coffee (57-96 mg), or brewed green tea (20-45 mg). Choosing hot cocoa helps reduce caffeine intake effectively.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation?
- A. Place a wedge pillow between the client's legs.
- B. Encourage the client to sit in a recliner.
- C. Allow the client to cross their legs when seated.
- D. Instruct the client to bend at the waist when picking up objects.
Correct Answer: A
Rationale: A wedge pillow maintains abduction, preventing hip dislocation. Recliners, leg crossing, or bending at the waist increase dislocation risk.