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A nurse is preparing to administer fluoxetine 30 mg PO daily to a client. The amount available is fluoxetine 10 mg tablets. 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: 3
Rationale: The correct answer is 3 tablets. To achieve a total of 30 mg, the nurse should administer 3 tablets of 10 mg each (10 mg x 3 = 30 mg). Other choices are incorrect because: A) 1 tablet is not enough to reach 30 mg, B) 2 tablets only add up to 20 mg, C) 4 tablets exceed the required dose, D) 5 tablets exceed the required dose, E) 6 tablets exceed the required dose, F) 7 tablets exceed the required dose, G) 8 tablets exceed the required dose.
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A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Obtain a 12-lead ECG.
- B. Suggest that the client use a salt substitute.
- C. Advise the client to add citrus juices and bananas to her diet.
- D. Obtain a blood sample for a serum sodium level.
Correct Answer: A
Rationale: The correct answer is A: Obtain a 12-lead ECG. A potassium level of 6.8 mEq/L indicates hyperkalemia, which can lead to serious cardiac arrhythmias. Therefore, obtaining an ECG is crucial to assess for any potential cardiac abnormalities. Choice B is incorrect as salt substitutes often contain potassium, exacerbating the issue. Choice C is incorrect as citrus juices and bananas are high in potassium, which should be avoided in hyperkalemia. Choice D is incorrect as it focuses on sodium levels, not addressing the immediate concern of hyperkalemia.
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 providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I’ll be sure to eat more foods with vitamin K.
- B. I’ll take aspirin for my headaches.
- C. I’ll use my electric razor for shaving.
- D. It’s okay to have a couple of glasses of wine with dinner each evening.
Correct Answer: C
Rationale: The correct answer is C: "I’ll use my electric razor for shaving." This statement indicates an understanding of the teaching because warfarin is a blood thinner, increasing the risk of bleeding. Using an electric razor reduces the risk of nicks and cuts, which could lead to excessive bleeding.
Incorrect choices:
A: "I’ll be sure to eat more foods with vitamin K." - Eating more vitamin K-rich foods can interfere with the effectiveness of warfarin.
B: "I’ll take aspirin for my headaches." - Aspirin is a blood thinner and should not be taken along with warfarin.
D: "It’s okay to have a couple of glasses of wine with dinner each evening." - Alcohol can interact with warfarin and increase the risk of bleeding.
Choosing option C demonstrates the client's understanding of the importance of minimizing the risk of bleeding while on warfarin therapy.
A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Remove all objects that contain latex from the client’s room.
- B. Verify the client’s medication prescriptions do not include cephalosporin.
- C. Notify dietary services to adjust the client’s diet.
- D. Have the client purchase a medication alert bracelet to wear in the hospital.
Correct Answer: B
Rationale: The correct answer is B: Verify the client’s medication prescriptions do not include cephalosporin. This is essential because cephalosporins are antibiotics that share a similar structure to penicillin and can potentially cause an allergic reaction in individuals with a penicillin allergy. By ensuring that the client's medication prescriptions do not include cephalosporin, the nurse is taking a proactive step to prevent any adverse reactions.
Removing objects containing latex (choice A) is not directly related to the client’s penicillin allergy. Notifying dietary services to adjust the client’s diet (choice C) is unnecessary as the allergy is to penicillin, not food. Having the client purchase a medication alert bracelet (choice D) is not as immediate or essential as verifying medication prescriptions.