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A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz. of which of the following beverages contains the least amount of caffeine?
- A. Hot cocoa
- B. Cola soft drink
- C. Instant coffee
- D. Brewed green tea
Correct Answer: A
Rationale: Hot cocoa contains approximately 5 mg of caffeine per 240 mL, significantly less than cola soft drink (24-31 mg), instant coffee (57-96 mg), or brewed green tea (20-45 mg). Choosing hot cocoa helps reduce caffeine intake effectively.
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A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience weight loss while taking this medication.
- C. You need to avoid tyramine-rich foods while taking this medication.
- D. You can expect symptom improvement within 24 hours.
Correct Answer: A
Rationale: Fluoxetine is often taken at bedtime to minimize daytime side effects like agitation. Weight changes vary, tyramine isn't a concern, and effects take weeks.
A nurse is reinforcing teaching with a client who has a new prescription for omeprazole. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You might need to take this medication for up to 8 weeks.
- C. Stop taking this medication if you experience heartburn.
- D. Take this medication with an antacid for best results.
Correct Answer: B
Rationale: Omeprazole may require 4-8 weeks for full effect in treating conditions like GERD. It's taken before meals, not bedtime, stopping for heartburn is incorrect, and antacids don't enhance it.
A nurse is caring for a client who is postoperative following a lumbar laminectomy. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate with a straight back.
- B. Instruct the client to avoid turning at the waist.
- C. Allow the client to sit in a chair for 2 hr at a time.
- D. Apply a heating pad to the surgical site.
Correct Answer: B
Rationale: Avoiding waist turning prevents strain on the surgical site. Ambulation should allow natural posture, prolonged sitting risks stiffness, and heating pads may increase swelling.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Which of the following actions should the nurse take?
- A. Infuse the blood over 6 hr.
- B. Check the client's temperature every 30 min.
- C. Administer the blood through a 22-gauge IV catheter.
- D. Flush the IV line with dextrose 5% in water before infusion.
Correct Answer: B
Rationale: Monitoring temperature every 30 minutes detects transfusion reactions early. Blood infuses over 2-4 hours, requires a large-gauge catheter, and saline, not dextrose, is used.
A nurse is caring for a client who has a new prescription for heparin. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: C
Rationale: Heparin's anticoagulant effect is monitored via PTT to ensure therapeutic dosing. Potassium, hemoglobin, or BUN aren't directly affected by heparin.