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A nurse is preparing to administer amitriptyline 150 mg PO at bedtime. The amount available is amitriptyline 75 mg tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: The nurse should administer 2 tablets of amitriptyline 75 mg each to achieve a total dose of 150 mg. Since each tablet is 75 mg, 2 tablets would equal 150 mg. This ensures the patient receives the prescribed dose accurately. Other choices are incorrect because administering 1 tablet would result in only 75 mg, insufficient for the prescribed dose. Administering 3 tablets would exceed the prescribed dose, leading to potential overdose. Choices above 3 tablets are also incorrect as they would significantly exceed the prescribed 150 mg dose, risking adverse effects.
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A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Exophthalmos
- B. Photophobia
- C. Lethargy
- D. Weight loss
Correct Answer: C
Rationale: Rationale: Hypothyroidism is characterized by decreased thyroid hormone levels, leading to symptoms such as lethargy due to slowed metabolism. Exophthalmos (bulging eyes) is associated with hyperthyroidism. Photophobia (sensitivity to light) is not a common symptom of hypothyroidism. Weight loss is more indicative of hyperthyroidism due to increased metabolism. Therefore, the correct answer is C: Lethargy, as it aligns with the expected findings in hypothyroidism.
A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification?
- A. The health care proxy does not go into effect until I am incapable of making decisions.
- B. I have to choose a family member as my health proxy.
- C. I can change who I designate as my health care proxy at any time.
- D. If I become incapacitated, end-of-life choices will be made by my proxy.
Correct Answer: B
Rationale: The correct answer is B: "I have to choose a family member as my health proxy." This statement indicates a need for clarification because it is incorrect. The client can choose any competent adult to be their health care proxy, not just a family member. This misconception may limit the client's options and understanding of their rights.
Incorrect choices:
A: This statement is correct as the health care proxy only goes into effect when the client is incapable of making decisions.
C: This statement is correct as the client can change their designated health care proxy at any time.
D: This statement is correct as the health care proxy will make end-of-life choices if the client becomes incapacitated.
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?
- A. Leave the pad in place for at least 40 minutes
- B. Set the pad’s temperature to 42.2°C (108°F)
- C. Use safety pins to keep the pad in place
- D. Stop the treatment if the client’s skin becomes red
Correct Answer: D
Rationale: The correct answer is D: Stop the treatment if the client’s skin becomes red. This is important because redness indicates potential skin damage or burns due to excessive heat exposure. It is crucial to monitor the client's skin during heat application to prevent harm. Choice A is incorrect because leaving the pad in place for a specific duration can lead to skin damage if the temperature is too high. Choice B is incorrect as setting the pad's temperature too high can cause burns. Choice C is incorrect as safety pins can cause injury or discomfort to the client. Therefore, the correct action is to closely monitor the client's skin for any signs of redness and stop the treatment immediately if redness occurs to prevent further harm.
A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will wipe from the back to front with the cleaning cloth.
- B. I need to urinate a small amount in the toilet before collecting the sample.
- C. I should let the urine cool to room temperature before sending it to the lab.
- D. I should not collect a urine sample when I am menstruating.
Correct Answer: B
Rationale: Correct Answer: B - "I need to urinate a small amount in the toilet before collecting the sample."
Rationale:
1. This statement indicates the client understands the importance of collecting a midstream urine sample.
2. By urinating a small amount first, the initial stream clears any bacteria present in the urethra, ensuring a more accurate sample.
3. Collecting a midstream sample helps to avoid contamination from the surrounding genital area.
4. This method is essential for accurate urinalysis results and diagnosis of potential urinary tract infections.
Incorrect Choices:
A: Incorrect - Wiping from back to front can introduce bacteria from the anal region into the urethra, leading to contamination.
C: Incorrect - Cooling the urine to room temperature is not necessary for a midstream urine sample collection.
D: Incorrect - Menstruation does not interfere with the accuracy of a midstream urine sample collection.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
- A. The medication will reduce inflammation.
- B. The medication will decrease coughing episodes.
- C. The medication will prevent wheezing.
- D. The medication will open the airway.
- E. The medication will stimulate the flow of mucus.
Correct Answer: C,D
Rationale: Correct Answer: C,D
Rationale:
C: The medication will prevent wheezing. Albuterol is a bronchodilator that works by relaxing the muscles in the airways, preventing and relieving wheezing.
D: The medication will open the airway. Albuterol acts by opening the airways, making it easier for the client to breathe.
Summary:
A: The medication will reduce inflammation. Albuterol does not directly reduce inflammation; it primarily works as a bronchodilator.
B: The medication will decrease coughing episodes. While albuterol may indirectly reduce coughing by improving breathing, its primary action is not to decrease coughing.
E: The medication will stimulate the flow of mucus. Albuterol does not stimulate mucus flow; it primarily works to open the airways and relieve bronchospasm.