Nokea
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Remind the client of the day and time often.
- B. Offer the client several choices at mealtimes.
- C. Avoid discussing the client's fears.
- D. Alternate daily caregivers.
Correct Answer: A
Rationale: Frequent orientation to time and place reduces confusion in delirium. Multiple choices can overwhelm, discussing fears supports emotional needs, and consistent caregivers minimize disorientation.
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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 caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
- A. Elevate the arm.
- B. Document the infiltration.
- C. Stop the infusion.
- D. Apply a warm compress.
Correct Answer: C
Rationale: Stopping the infusion is the priority to prevent further fluid infiltration, which can cause tissue damage. Elevation, documentation, and compresses follow after halting the infusion.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 4 hr.
- B. Irrigate the catheter with sterile water every 2 hr.
- C. Check the catheter tubing for blood clots.
- D. Administer an antibiotic prophylactically.
Correct Answer: C
Rationale: Checking for clots ensures catheter patency, critical for irrigation. Output monitoring is secondary, manual irrigation isn't routine, and antibiotics depend on orders.
A nurse is reinforcing teaching with a client who has a new prescription for levofloxacin. Which of the following instructions should the nurse include?
- A. Take this medication with an antacid to prevent stomach upset.
- B. You might experience tendon pain while taking this medication.
- C. You need to refrigerate this medication.
- D. You should avoid drinking water after taking this medication.
Correct Answer: B
Rationale: Levofloxacin can cause tendonitis or rupture, a serious side effect. Antacids reduce absorption, refrigeration isn't needed, and hydration is encouraged.
A nurse is collecting data from a client who has an arm cast newly applied. Which of the following findings should the nurse report to the provider?
- A. The client reports discomfort at the cast edges.
- B. The client can wiggle their fingers freely.
- C. The cast feels warm to the touch.
- D. The client reports mild pain at the fracture site.
Correct Answer: A
Rationale: Discomfort at cast edges may indicate pressure points or improper fit, requiring immediate attention. Finger movement, warmth, and mild pain are expected.