Nokea
A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid crowded places to reduce my risk of infection.
- B. I will take this medication on an empty stomach.
- C. I will stop taking this medication if I experience nausea.
- D. I will take this medication for 2 weeks and then stop.
Correct Answer: A
Rationale: The correct answer is A: 'I will avoid crowded places to reduce my risk of infection.' When taking prednisone, clients should avoid crowded places to reduce the risk of infection due to its immunosuppressive effects. Choice B is incorrect because prednisone is usually taken with food to reduce stomach upset. Choice C is incorrect because clients should not stop taking prednisone abruptly, even if they experience nausea. Choice D is incorrect because prednisone should be tapered off gradually under healthcare provider guidance instead of being stopped abruptly after 2 weeks.
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A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Administer ibuprofen 400 mg PO
- B. Administer oxycodone 10 mg PO
- C. Reposition the client to the unaffected side
- D. Apply a cold compress to the affected knee
Correct Answer: B
Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.
A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?
- A. Heat the feeding to 105°F (40.6°C).
- B. Elevate the head of the bed to 45 degrees.
- C. Flush the tube with 0.9% sodium chloride.
- D. Verify the pH of the gastric aspirate.
Correct Answer: D
Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.
A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?
- A. Limit your fluid intake to 3 liters per day.
- B. Increase your fluid intake to 5 liters per day.
- C. Avoid drinking more than 1 liter of fluid per day.
- D. You can drink as much fluid as you want during meals.
Correct Answer: C
Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.
A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of furosemide. Which of the following findings indicates the nurse should increase the client's infusion rate?
- A. Urine output of 20 mL/hr
- B. Heart rate of 90/min
- C. Sodium level of 138 mEq/L
- D. Weight gain of 1 kg in 24 hr
Correct Answer: D
Rationale: A weight gain of 1 kg in 24 hours can indicate fluid retention and worsening heart failure, requiring an increase in diuresis. This finding suggests that the current diuretic therapy is not effective enough to manage the fluid overload, necessitating an increase in the infusion rate of furosemide. Choices A, B, and C are not directly related to the need for an increase in diuretic therapy in heart failure patients. Urine output of 20 mL/hr, a heart rate of 90/min, and a sodium level of 138 mEq/L are important parameters to monitor but do not specifically indicate the need to increase the infusion rate of furosemide.
A client who is at 36 weeks of gestation is scheduled for a nonstress test (NST). Which of the following statements by the client indicates an understanding of the teaching?
- A. I should fast for 12 hours before the test.
- B. I should expect the test to take about 10 minutes.
- C. I should have a full bladder for this test.
- D. I will need to have my blood glucose checked before the test.
Correct Answer: B
Rationale: The correct answer is B. The nonstress test typically takes about 10 minutes and evaluates the fetal heart rate in response to fetal movement. Having a full bladder or fasting for 12 hours is not required for a nonstress test. Checking blood glucose levels is not part of the nonstress test procedure.