Nokea
A nurse is reinforcing teaching with a client who has a new prescription for a nicotine nasal spray. Which of the following instructions should the nurse include?
- A. Use the spray every 2 hours.
- B. Avoid using it for more than 6 months.
- C. Inhale deeply after spraying.
- D. Store the spray in the refrigerator.
Correct Answer: B
Rationale: Avoiding use of nicotine nasal spray for more than 6 months prevents dependency and supports smoking cessation.
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A nurse is assisting with the care of a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
- A. Check gastric residual volume every 8 hours.
- B. Flush the tube with cold water every 4 hours.
- C. Position the client flat during feeding.
- D. Change the feeding bag every 72 hours.
Correct Answer: C
Rationale: Positioning the client with the head of the bed elevated during feeding reduces the risk of aspiration, a critical safety measure.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Monitor the client's weight weekly.
- B. Check the client's blood glucose every 12 hours.
- C. Change the TPN bag every 48 hours.
- D. Administer TPN through a peripheral IV line.
Correct Answer: B
Rationale: Checking blood glucose every 12 hours is necessary, as TPN contains high dextrose concentrations that can cause hyperglycemia.
A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?
- A. BUN 18 mg/dL
- B. Serum creatinine 1.0 mg/dL
- C. Urine output 12 mL/hr
- D. Urine specific gravity 1.020
Correct Answer: C
Rationale: Urine output 12 mL/hr is correct. A urine output of 12 mL/hr is low and indicates oliguria, which is a concern in the context of dehydration. The normal urine output for an adult is at least 30 mL/hr. A decrease in urine output suggests that the kidneys are not receiving adequate blood flow, which could indicate severe dehydration and requires immediate attention from the provider.
A nurse is reinforcing teaching with a client who has a new prescription for warfarin. Which of the following over-the-counter medications should the nurse identify as safe for use with warfarin?
- A. Docusate
- B. Ibuprofen
- C. Aspirin
- D. Omeprazole
Correct Answer: A
Rationale: Docusate is correct. Docusate is a stool softener, and it does not have a significant effect on blood clotting. Therefore, it is considered safe for use with warfarin, which requires careful monitoring to avoid interactions that may increase bleeding risks.
A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the nares.
- B. Secure the cannula with tape on the forehead.
- C. Check the nares for irritation.
- D. Increase the flow rate if the client reports dryness.
Correct Answer: C
Rationale: Checking the nares for irritation ensures early detection of skin breakdown from prolonged cannula use.