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A nurse is reinforcing teaching with a client who has a new prescription for a nitroglycerin sublingual tablet. Which of the following instructions should the nurse include?
- A. Swallow the tablet with water.
- B. Take the tablet every 10 minutes for chest pain.
- C. Store the tablets in a dark container.
- D. Keep the tablet under the tongue for 2 hours.
Correct Answer: C
Rationale: Storing nitroglycerin tablets in a dark container protects them from light, which can degrade the medication.
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A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?
- A. We will frequently check the top of his ears for sores.
- B. We can turn the oxygen up to 10 when he has trouble breathing.
- C. We can use petroleum jelly to keep his nares moist.
- D. We will need to remove the nasal cannula when he is eating.
Correct Answer: A
Rationale: Frequently checking the top of the ears for sores is correct. The nasal cannula tubing can cause pressure injuries behind the ears over time. The family should check for redness or sores and use protective padding or adjust the tubing as needed.
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
- A. Cover the wound with sterile, saline-soaked gauze.
- B. Hold gentle, direct pressure on the protruding organ.
- C. Place the client's knees in an extended position.
- D. Raise the head of the bed to a 45° angle.
Correct Answer: A
Rationale: Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.
A nurse is caring for a client who has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Cholesterol
- D. Albumin
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, so monitoring potassium levels is essential to prevent complications like arrhythmias.
A nurse is caring for a client who has a new diagnosis of Sjögren's syndrome. Which of the following findings should the nurse expect?
- A. Dry eyes
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Dry eyes are a hallmark symptom of Sjögren's syndrome due to decreased tear production from autoimmune gland dysfunction.
A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?
- A. The telephone numbers of the clients
- B. The room numbers of the clients
- C. The diagnoses of the clients
- D. The names of the clients' nearest relatives
Correct Answer: A
Rationale: Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.