Nokea
A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
- A. The client fell because the assistive personnel did not place nonskid slippers on the client.
- B. Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'
- C. An incident report has been completed and sent to risk management.
- D. The client does not appear to have any injuries resulting from the fall.
Correct Answer: B
Rationale: Quoting the client's statement provides an objective account of the event.
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The client reports he has headaches after taking chewable isosorbide dinitrate.
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. Swallow the tablet whole to minimize your headaches.
- B. You can discontinue the medication until the headache goes away.
- C. You should take the medication on an empty stomach to prevent a headache.
- D. The headaches should decrease as you get used to the medication.
Correct Answer: D
Rationale: Headaches are a common side effect of isosorbide that typically lessen over time.
A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
- A. Difficulty swallowing
- B. Constipation
- C. Urinary retention
- D. Clenched teeth
Correct Answer: D
Rationale: Clenched teeth indicate ongoing pain despite the epidural.
A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
- A. Educate the infant's guardians about exchange transfusion.
- B. Administer granulocyte colony-stimulating factor.
- C. Initiate droplet precautions.
- D. Monitor the infant's lymphocyte count.
Correct Answer: D
Rationale: Monitoring lymphocyte count tracks HIV progression in infants.
The client was prescribed azithromycin 1 g PO once.
A nurse in a health clinic is assisting in the care of a client diagnosed with chlamydia. The client was prescribed azithromycin 1 g PO once. Which of the following allergy findings in the client's history should the nurse report to the provider?
- A. Allergy to tetracyclines
- B. Allergy to sulfonamides
- C. Allergy to macrolides
- D. Allergy to penicillins
Correct Answer: C
Rationale: Azithromycin is a macrolide; an allergy to macrolides contraindicates its use.
A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching?
- A. The client's extremity should be elevated after the cast is applied.
- B. The client should use a hair dryer on a warm setting to relieve itching inside the cast.
- C. The client should keep the cast covered until it is dry.
- D. The client can shower with the cast after 24 hr.
Correct Answer: A
Rationale: Elevating the extremity reduces swelling post-cast application.