Nokea
A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse?
- A. Take this in the morning 1 hour before breakfast.
- B. Take this with your other stomach medications.
- C. Take your heart medication 2 hours after sucralfate.
- D. You might experience constipation while taking this.
Correct Answer: B
Rationale: Sucralfate (B) should not be taken with other stomach medications, as it forms a protective barrier, reducing their absorption. Timing (A, C) and constipation (D) are correct.
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A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:
- A. Warm and nurturing
- B. Open and flexible
- C. Firm and consistent
- D. Nonintrusive and passive
Correct Answer: C
Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
- A. the muscles
- B. the cerebellum
- C. the kidneys
- D. the leg bones
Correct Answer: A
Rationale: the muscles. Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- 'myo' --which typically means muscle.
A nurse is preparing an educational presentation on herbal supplements for the local community center. The nurse anticipates discussion of saw palmetto to what type of clients?
- A. Clients diagnosed with dyslipidemia
- B. Clients experiencing major depression
- C. Clients with benign prostatic hyperplasia
- D. Perimenopausal clients experiencing hot flashes
Correct Answer: C
Rationale: Saw palmetto is commonly used for benign prostatic hyperplasia (C) to relieve urinary symptoms. It is not indicated for dyslipidemia (A), depression (B), or hot flashes (D).
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm, as uterine atony is the primary cause of bleeding in the first hour after delivery.
The client is admitted to the unit with a potassium level of $2.4 \mathrm{meq} / \mathrm{L}$. The client with a potassium level of $2.4 \mathrm{meq} / \mathrm{L}$ would exhibit symptoms of:
- A. Peaked T waves
- B. U waves
- C. Muscle rigidity
- D. Rapid respirations
Correct Answer: B
Rationale: Hypokalemia (low potassium, 2.4 meq/L) causes symptoms like U waves on ECG, muscle weakness, and cramps. Peaked T waves occur in hyperkalemia. Muscle rigidity is not typical, and rapid respirations are more associated with acid-base imbalances.