Nokea
A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?
- A. Dehydration is treated with calcium supplements
- B. Dehydration can increase the risk of preterm labor
- C. Dehydration can increase gastroesophageal reflux
- D. Dehydration is caused by a decreased hemoglobin and hematocrit
Correct Answer: B
Rationale: The correct statement the nurse should make is that dehydration can increase the risk of preterm labor. Dehydration reduces amniotic fluid and uterine blood flow, potentially leading to preterm contractions. Choice A is incorrect because dehydration is not treated with calcium supplements but rather with adequate fluid intake. Choice C is incorrect as dehydration does not directly increase gastroesophageal reflux. Choice D is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by insufficient fluid intake or excessive fluid loss.
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A nurse is caring for a client who is scheduled for a colonoscopy. Which of the following findings should the nurse report to the provider?
- A. Client reports taking ibuprofen daily
- B. Client has a history of asthma
- C. Client reports drinking one glass of wine daily
- D. Client has a history of diverticulitis
Correct Answer: A
Rationale: The correct answer is A. Ibuprofen is an NSAID that can increase the risk of bleeding during a colonoscopy due to its effects on platelet function. It is important to report this finding to the provider to consider alternative pain management options. Choices B, C, and D are not the most pertinent to report for a colonoscopy. Asthma and a history of diverticulitis are relevant medical history but do not directly impact the colonoscopy procedure. Drinking one glass of wine daily is not a concern specifically related to the colonoscopy procedure.
A nurse is teaching a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?
- A. "You should expect to feel an improvement in your symptoms within 1 week."
- B. "You may experience weight gain while taking this medication."
- C. "You should take this medication in the morning to prevent insomnia."
- D. "You should stop taking this medication if you experience dry mouth."
Correct Answer: B
Rationale: The correct statement the nurse should include is that the client may experience weight gain while taking fluoxetine. Weight gain is a common side effect of fluoxetine, and patients should be informed about this potential issue. Stating that the client should expect improvement in symptoms within 1 week (Choice A) is incorrect as fluoxetine may take a few weeks to have a noticeable effect. Taking the medication in the morning to prevent insomnia (Choice C) is not necessary since fluoxetine can be taken at any time of the day. Instructing the client to stop taking the medication if experiencing dry mouth (Choice D) is misleading, as dry mouth is a common but usually not serious side effect of fluoxetine.
A nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the nurse take?
- A. Check for residual feeding contents.
- B. Administer the feeding through a large-bore syringe.
- C. Flush the tube with 10 mL of water after feeding.
- D. Administer the feeding at room temperature.
Correct Answer: C
Rationale: The correct action for the nurse to take when preparing to administer an intermittent enteral feeding through a nasogastric tube is to flush the tube with 10 mL of water after feeding. This helps maintain tube patency and prevent clogging. Choice A, checking for residual feeding contents, is not the immediate action to take before administering the feeding. Choice B, administering the feeding through a large-bore syringe, is not the recommended method for administering enteral feedings. Choice D, administering the feeding at room temperature, is important but not the immediate action related to tube maintenance.
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
- A. Substernal retractions
- B. Hematuria
- C. Temperature of 37.9°C (100.2°F)
- D. Sneezing
Correct Answer: A
Rationale: Substernal retractions indicate respiratory distress in a sickle-cell client, which can be a sign of acute chest syndrome. This condition is a serious complication of sickle-cell anemia characterized by chest pain, fever, cough, and shortness of breath. Reporting this symptom promptly is crucial for timely intervention. Choice B, hematuria, is not typically associated with acute chest syndrome but may indicate other issues such as a urinary tract infection. Choice C, a temperature of 37.9°C (100.2°F), is slightly elevated but not a specific indicator of acute chest syndrome. Choice D, sneezing, is not a typical symptom of acute chest syndrome and would not warrant immediate reporting to the provider in this context.
A nurse is providing teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?
- A. Avoid taking this medication with antacids.
- B. Contact your provider if you experience visual changes.
- C. Increase your intake of foods high in potassium.
- D. You may experience increased urination while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: 'Contact your provider if you experience visual changes.' Visual changes, such as blurred or yellow vision, can indicate digoxin toxicity and should be reported immediately to the healthcare provider for further evaluation and management. Choice A is incorrect because digoxin can be taken with antacids. Choice C is incorrect because increasing potassium intake can lead to hyperkalemia when taking digoxin. Choice D is incorrect because increased urination is not a common side effect of digoxin.