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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. Brewed green tea
- B. Cola soft drink
- C. Hot cocoa
- D. Instant coffee
Correct Answer: C
Rationale: Hot cocoa has the least caffeine compared to tea, soda, and coffee.
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The child has pertussis.
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
- A. Facial erythema
- B. Peeling of the hands and feet
- C. Fever
- D. Beefy, red tongue
Correct Answer: C
Rationale: Fever is a common symptom of pertussis.
The client consumed alcohol 2 days after taking disulfiram.
A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
- A. Constipation
- B. Dry skin
- C. Hypotension
- D. Urinary retention
Correct Answer: C
Rationale: Disulfiram-alcohol reaction causes hypotension among other symptoms.
The client has pyelonephritis and is receiving gentamicin via IV infusion.
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?
- A. New onset of hearing loss
- B. Slurred speech
- C. Constipation
- D. Hypotension
Correct Answer: A
Rationale: Gentamicin can cause ototoxicity, leading to hearing loss.
The client has mild hypertension.
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should exercise for 15 minutes two times per week.
- B. I should decrease my salt intake to 2 grams per day.
- C. I will set my blood pressure goal at 130 over 84.
- D. I can have two glasses of wine with dinner.
Correct Answer: B
Rationale: Reducing salt to 2 grams daily helps manage hypertension, showing understanding.
A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following instructions should the nurse include in the teaching?
- A. Carry your newborn back to the nursery in your arms when you need to rest.
- B. Request that the nurses show their nursing license prior to removing your newborn from the room.
- C. Alert the staff if any of your newborn's identification bands are missing.
- D. Leave your newborn in the bassinet in your room while you use the bathroom.
Correct Answer: C
Rationale: Missing ID bands increase abduction risk, requiring immediate staff notification.