Nokea
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Weight loss
- B. Decreased blood pressure
- C. Decreased skin turgor
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate pulmonary edema from fluid overload. Weight loss, low blood pressure, or poor skin turgor suggest dehydration, not overload.
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A nurse is reinforcing teaching with a client who has a new prescription for omeprazole. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication at bedtime.
- B. I might need to take this medication for several weeks.
- C. I can take this medication with an antacid if I have heartburn.
- D. I should stop taking this medication if I feel better.
Correct Answer: B
Rationale: Omeprazole often requires weeks of treatment for full effect, showing understanding. It's taken before meals, antacids don't enhance it, and stopping early risks relapse.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone. Which of the following instructions should the nurse include?
- A. You should take this medication on an empty stomach.
- B. You might experience weight gain while taking this medication.
- C. You can stop taking this medication as soon as your symptoms improve.
- D. You need to avoid eating dairy products while taking this medication.
Correct Answer: B
Rationale: Prednisone can cause weight gain due to fluid retention and appetite increase. It's taken with food, tapered gradually, and dairy isn't restricted.
A nurse is reinforcing teaching with a client who has a new prescription for tramadol. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I might feel sleepy while taking this medication.
- C. I need to avoid sunlight.
- D. I can increase the dose if my pain gets worse.
Correct Answer: B
Rationale: Tramadol can cause drowsiness, showing understanding. Food isn't required, sunlight isn't a concern, and dose increases need provider approval.
A nurse is reinforcing teaching with a client who has a new prescription for venlafaxine. Which of the following statements should the nurse include?
- A. You should take this medication with food.
- B. You might experience headaches while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You can expect symptom relief within 24 hours.
Correct Answer: B
Rationale: Venlafaxine can cause headaches, a common side effect. Food enhances absorption, caffeine isn't restricted, and relief takes weeks.
A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following findings should the nurse report to the provider?
- A. The client reports chest discomfort.
- B. The client's temperature is 38.4°C (101.1°F).
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/80 mm Hg.
Correct Answer: B
Rationale: A temperature of 38.4°C suggests infection, requiring reporting. Chest discomfort, minimal drainage, and normal BP are expected or less urgent.