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A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper CPAP use?
- A. There is one finger width between the strap on the mask and the client's face.
- B. The therapeutic dose of albuterol is being inhaled.
- C. The mask fits loosely so air can escape from underneath.
- D. The mask is secured over the client's mouth and the client's nose is uncovered.
Correct Answer: A
Rationale: There is one finger width between the strap on the mask and the client's face is correct. A properly fitted CPAP mask should have a snug fit, with a space of about one finger width between the strap and the face to ensure adequate seal and comfort. A mask that is too tight can cause discomfort, while a loose mask may not provide the necessary pressure to treat sleep apnea.
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A nurse is reinforcing teaching with a client who has a new prescription for a nicotine lozenge. Which of the following instructions should the nurse include?
- A. Chew the lozenge like gum.
- B. Avoid drinking fluids while using the lozenge.
- C. Use the lozenge every 4 hours.
- D. Store the lozenges in the refrigerator.
Correct Answer: B
Rationale: Avoiding drinking fluids while using a nicotine lozenge ensures proper absorption of nicotine through the oral mucosa.
A nurse is caring for a client who has a new prescription for allopurinol. Which of the following laboratory values should the nurse monitor?
- A. Uric acid
- B. Hemoglobin A1c
- C. Serum creatinine
- D. Cholesterol
Correct Answer: A
Rationale: Allopurinol reduces uric acid levels, so monitoring uric acid ensures the medication's effectiveness in treating gout.
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.
A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?
- A. Headaches with aura
- B. History of mononucleosis 1 year ago.
- C. Irregular menstrual cycles
- D. Gastroesophageal reflux disease.
Correct Answer: A
Rationale: Headaches with aura is correct. Headaches with aura, a warning sign that can precede a migraine, are a contraindication for the use of oral contraceptives. This is because oral contraceptives increase the risk of stroke, especially in women who experience migraines with aura.
A nurse is caring for a client who has a new prescription for amlodipine. Which of the following adverse effects should the nurse monitor for?
- A. Peripheral edema
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Amlodipine, a calcium channel blocker, commonly causes peripheral edema due to vasodilation.