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A nurse is reinforcing discharge teaching about sublingual nitroglycerin with a client who has angina. Which of the following statements indicates an understanding of the instructions?
- A. I understand that the medication can slow my heart rate.
- B. I am going to take the medication with food.
- C. I will take the medication every 10 minutes until the pain goes away.
- D. I should feel the effects of the medication within 5 minutes.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Nitroglycerin is a fast-acting medication used to relieve angina symptoms. Choosing option D shows understanding because nitroglycerin should provide relief within 5 minutes if the medication is effective. This rapid onset is crucial in managing acute angina attacks. Taking the medication every 10 minutes (C) could lead to overdose and severe side effects. Slow heart rate (A) is not a common side effect of nitroglycerin. Taking with food (B) may delay absorption and reduce effectiveness.
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A nurse in a mental health facility is collecting data from a client taking lithium. Which of the following information should the nurse report to the provider as an indication of lithium toxicity?
- A. Dry cough
- B. Elevated blood pressure
- C. Stooped posture
- D. Slurred speech
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Lithium toxicity can manifest as neurological symptoms such as slurred speech due to its effects on the central nervous system. A dry cough (A) is not typically associated with lithium toxicity. Elevated blood pressure (B) may be a sign of other conditions but is not specific to lithium toxicity. Stooped posture (C) is more indicative of musculoskeletal issues rather than lithium toxicity. In summary, slurred speech is a key neurological symptom of lithium toxicity, making it the correct choice in this scenario.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone to treat rheumatoid arthritis. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I should watch for weight loss.
- B. I should increase the sodium in my diet.
- C. I will take this medication on an empty stomach.
- D. I will report a sore throat to my provider.
Correct Answer: D
Rationale: The correct answer is D: "I will report a sore throat to my provider." This is the correct answer because prednisone can suppress the immune system, increasing the risk of infections like thrush or sore throat. Reporting these symptoms promptly is crucial to prevent complications.
Choice A is incorrect because prednisone can actually cause weight gain. Choice B is incorrect because prednisone can lead to fluid retention, so increasing sodium intake is not recommended. Choice C is incorrect because prednisone should be taken with food to reduce stomach upset.
Nurses' Notes
0800:
Client reports frequent cough, wheezing, and tightness of chest. Bilateral breath sounds with scattered inspiratory and expiratory wheezes.
1000:
Reinforced teaching about newly prescribed medications.
Click to highlight the instructions the nurse should reinforce to the client.
- A. Take your albuterol when you are having difficulty breathing.
- B. Hold your breath for 20 seconds when taking your albuterol.
- C. Take the salmeterol 5 minutes before the albuterol when you need both medications.
- D. Take the salmeterol 2 times each day.
- E. Rinse out your mouth after taking the fluticasone.
- F. Take the fluticasone as needed for an asthma attack.
Correct Answer: A,D,E
Rationale: Sure, here is a detailed explanation for each choice:
A: Taking albuterol during difficulty breathing helps relieve symptoms promptly.
D: Salmeterol should be taken twice daily for optimal effectiveness.
E: Rinsing mouth after fluticasone reduces the risk of oral thrush.
Incorrect choices:
B: Holding breath doesn't affect albuterol efficacy.
C: Timing salmeterol before albuterol isn't necessary.
F: Fluticasone is a controller, not a rescue inhaler.
A nurse is reinforcing teaching about cyclosporine with a client who is postoperative following a kidney transplant. Which of the following statements indicates an understanding of the information?
- A. I can take ibuprofen to treat headaches.
- B. I will get out of bed slowly in the morning.
- C. I can expect hair loss when taking this medication.
- D. I will call my doctor if I have a sore throat.
Correct Answer: D
Rationale: The correct answer is D: "I will call my doctor if I have a sore throat." This statement indicates an understanding of the potential side effects of cyclosporine, one of which is immunosuppression leading to increased susceptibility to infections. By recognizing the importance of reporting a sore throat promptly, the client demonstrates awareness of the need for close monitoring and early intervention to prevent serious complications.
Incorrect choices:
A: Taking ibuprofen can interact with cyclosporine and is not recommended.
B: Getting out of bed slowly is a general precaution but not specific to cyclosporine.
C: Hair loss is not a common side effect of cyclosporine.
E, F, G: No information is provided for these choices.
Nurses’ notes
Vital Signs
Medication Administration Record
Client reports tightness in the chest that radiates to the left arm. States pain as 7 on a scale of 0 to 10. Client is diaphoretic and short of breath.
Which of the following instructions should the nurse include when reinforcing teaching to the client about their medication? Select all that apply.
- A. Lie down with feet elevated if dizziness occurs while taking this medication.
- B. Apply the patch daily to a hairless area of the skin.
- C. The medication will be effective 30 to 45 min following application.
- D. Remove the patch 12 to 14 hr following application.
- E. Remove the patch if you experience a headache.
- F. Place the patch on the same area every day.
Correct Answer: A,B,D
Rationale: Correct answer: A, B, D
Rationale:
A: Instructing the client to lie down with feet elevated if dizziness occurs is important as it can prevent falls and injury.
B: Applying the patch to a hairless area of the skin ensures proper drug absorption and effectiveness.
D: Removing the patch after 12 to 14 hours prevents skin irritation and ensures the medication is not being overexposed.
Incorrect answer explanations:
C: The time frame given for medication effectiveness is inaccurate and may lead to confusion.
E: Removing the patch if experiencing a headache is not a standard instruction and may interfere with the medication's intended purpose.
F: Placing the patch on the same area daily can lead to skin irritation or decreased drug absorption due to buildup.