Nokea
A nurse is instructing a client about the use of nitroglycerin patches. The nurse should instruct the client to:
- A. Remove the patch every night.
- B. Apply the patch only when chest pain occurs.
- C. Change the site of the patch every day.
- D. Apply the patch only on alternate days.
Correct Answer: A,C
Rationale: Nitroglycerin patches require a daily nitrate-free interval (typically at night) to prevent tolerance, and the site should be rotated daily to avoid skin irritation.
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The nurse collecting data from the client is providing instructions regarding a new prescription for disulfiram. Which datum is important for the nurse to obtain before beginning the administration of this medication?
- A. When the last full meal was consumed
- B. When the last alcoholic drink was consumed
- C. If the client has a history of hyperthyroidism
- D. If the client has a history of diabetes insipidus
Correct Answer: B
Rationale: Disulfiram may be used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. Therefore, it is important for the nurse to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.
The nurse is teaching a client with hypertension about dietary modifications. Which food should the nurse recommend limiting?
- A. Fresh fruits
- B. Lean proteins
- C. Canned soups
- D. Whole grains
Correct Answer: C
Rationale: Canned soups are high in sodium, which can exacerbate hypertension. Limiting sodium intake is a key dietary modification for blood pressure control.
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
- A. Administer acetaminophen.
- B. Take the client's blood pressure.
- C. Discontinue the transfusion.
- D. Check the infusion rate of the blood.
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.
A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?
- A. Breast-feed only with the unaffected breast.
- B. Stop breast-feeding because you probably have an infection.
- C. Notify your health care provider because you may need medication.
- D. Continue breast-feeding since this is a normal response in breast-feeding mothers.
Correct Answer: C
Rationale: Based on the signs and symptoms presented by the client (particularly the elevated temperature), the primary health care provider needs to be notified because an antibiotic that is tolerated by the infant, as well as the mother, may be prescribed. The mother should continue to nurse on both breasts, but should start the infant on the unaffected breast while the affected breast lets down.
After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which of the following statements indicates that the client needs further instruction?
- A. Because I have hydramnios, I may gain weight.'
- B. Hydramnios has been associated with gastrointestinal disorders in the fetus.'
- C. I should continue to eat high-fiber foods and avoid constipation.'
- D. I can continue to work at my job at the automobile factory until labor starts.'
Correct Answer: D
Rationale: Severe hydramnios increases risks like preterm labor, requiring activity restrictions; continuing physically demanding work indicates a need for further teaching.