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A nurse is reinforcing teaching with a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?
- A. Take this medication every morning.
- B. You might experience a rapid heartbeat.
- C. You need to rinse your mouth after using this medication.
- D. You should use this medication to prevent asthma attacks.
Correct Answer: B
Rationale: Albuterol can cause tachycardia, a side effect to anticipate. It's used as needed, not daily, mouth rinsing is for steroids, and it treats, not prevents, attacks.
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A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?
- A. Countertransference
- B. Boundary crossing
- C. Promoting trust
- D. Veracity
Correct Answer: C
Rationale: Providing a meal addresses the client's immediate need, fostering trust and rapport. This action reflects responsiveness, not countertransference, boundary crossing, or truthfulness.
A nurse is reinforcing teaching with a client who has a new prescription for esomeprazole. Which of the following statements should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience headache while taking this medication.
- C. You need to avoid dairy products while taking this medication.
- D. You can take this medication with an antacid for best results.
Correct Answer: B
Rationale: Esomeprazole can cause headaches, a side effect to monitor. It's taken before meals, dairy isn't restricted, and antacids don't enhance efficacy.
A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?
- A. Place the client in a supine position.
- B. Ensure the device is kept below the level of the client's chest.
- C. Empty the collection chamber every 8 hr.
- D. Clamp the chest tube every 4 hr.
Correct Answer: B
Rationale: Keeping the drainage system below chest level ensures proper drainage and prevents backflow. Supine positioning may hinder drainage, routine emptying isn't needed, and clamping can interfere with suction.
A nurse is reinforcing teaching with a client who has a new prescription for pantoprazole. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You might experience diarrhea while taking this medication.
- C. You need to take this medication with an antacid.
- D. You should stop taking this medication if your symptoms improve.
Correct Answer: B
Rationale: Pantoprazole can cause diarrhea, a side effect to monitor. It's taken before meals, antacids aren't needed, and stopping early risks symptom recurrence.
A nurse is assisting with the care of a client who is at 38 weeks of gestation and in active labor. Which of the following actions should the nurse take?
- A. Apply counterpressure to the client's sacrum during contractions.
- B. Position the client in a supine position during contractions.
- C. Encourage the client to take deep, cleansing breaths between contractions.
- D. Administer oxygen at 2 L/min via nasal cannula during contractions.
Correct Answer: C
Rationale: Deep breaths between contractions promote relaxation and oxygenation. Counterpressure may help some, supine position risks vena cava compression, and oxygen isn't routinely needed.