Nokea
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.'
- B. I can put the tablet against my cheek and gum.'
- C. I should chew the tablet before I swallow it.'
- D. I should take this medication as soon as the pain begins.'
Correct Answer: A
Rationale: The correct answer is A: "I can take another dose after 2 minutes." This statement indicates an understanding of the teaching because sublingual nitroglycerin is typically used for acute chest pain relief due to angina, and the client should take another dose if the pain persists after 5 minutes, up to a total of 3 doses at 5-minute intervals. This is crucial for managing angina attacks effectively.
Choice B is incorrect because the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because the tablet should not be chewed but allowed to dissolve under the tongue. Choice D is incorrect because nitroglycerin should be taken at the onset of chest pain, not after the pain begins, for optimal efficacy.
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A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Pistolate
Correct Answer: B
Rationale: The correct answer is B: Infection. The kinked IV tubing and the urinary catheter bag lying next to the client in bed can lead to contamination of the catheter system, increasing the risk of a urinary tract infection. The kinked tubing can cause backup of urine, leading to bacterial growth, while the catheter bag being on the bed can introduce pathogens to the catheter. Infections can result in serious complications for the client if not addressed promptly. The other choices, A: Neurogenic bladder, C: Skin breakdown, and D: Pistolate, are not directly related to the scenario presented and do not pose an immediate risk based on the information provided.
A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A: Teach the client how to self-medicate using the PCA device. This is important because it empowers the client to control their pain management while ensuring safety. Teaching the client how to use the PCA device helps promote autonomy and ensures that the client is receiving the appropriate dose of medication as prescribed. Encouraging family members to press the button (B) may lead to inappropriate dosing and compromise the client's safety. Monitoring respiratory status (C) is important but should be done more frequently, such as every hour, as respiratory depression can occur with morphine use. Administering an oral opioid for breakthrough pain (D) may not be necessary if the client is able to self-medicate effectively with the PCA device.
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?'
- B. After this procedure, you will feel much better.'
- C. Tell me why you are scared to have this procedure.'
- D. Let's discuss your concerns about this procedure.'
Correct Answer: D
Rationale: Rationale: Option D is correct as it acknowledges the client's fear and opens the door for a discussion about their concerns, allowing the nurse to address them. It shows empathy and promotes client-centered care. Option A focuses solely on needles, which may not address the client's overall fear. Option B dismisses the client's feelings without addressing their fear. Option C asks for the reason but may not actively engage in addressing the fear. Overall, option D is the best choice as it demonstrates active listening and a willingness to address the client's specific concerns.
A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.