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A nurse is reinforcing teaching with a client who has a new prescription for bupropion. Which of the following statements should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods while taking this medication.
- D. You can expect immediate improvement in your mood.
Correct Answer: B
Rationale: Bupropion can cause dry mouth, a common side effect. It's taken in the morning, tyramine isn't a concern, and mood improvement takes weeks.
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A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Understands that everyone dies eventually
- B. Recognizes the parent will never wake up
- C. Expresses curiosity about the funeral service
- D. Believes death is punishment for bad behavior
Correct Answer: D
Rationale: Preschoolers often believe death is a punishment due to magical thinking. Understanding permanence or universal death is beyond their developmental stage.
A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.
- A. Discarding worksheets containing client information in a wastebasket
- B. Writing a client's diagnosis on the message board in the client's room
- C. Giving change of shift report to a nurse outside the client's room
- D. Discussing a client's prognosis with an assistive personnel who is caring for the client
Correct Answer: C
Rationale: Giving a shift report in a private setting prevents unauthorized individuals from overhearing, protecting confidentiality. Discarding worksheets improperly, writing diagnoses publicly, or discussing prognosis openly risks breaches.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take this medication on an empty stomach.
- B. You might experience a metallic taste in your mouth.
- C. You should stop taking this medication if you feel shaky.
- D. You need to limit your protein intake while taking this medication.
Correct Answer: B
Rationale: Metformin can cause a metallic taste, a common side effect to anticipate. It's taken with meals, shakiness requires glucose, and protein limits aren't needed.
A nurse is caring for a client who is postoperative following a hip replacement. Which of the following actions should the nurse take?
- A. Place an abduction pillow between the client's legs.
- B. Instruct the client to bend at the hip when sitting.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to cross their legs when seated.
Correct Answer: A
Rationale: An abduction pillow prevents dislocation by maintaining hip alignment. Bending, warm compresses, and leg crossing increase dislocation risk.
A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the client's nares.
- B. Secure the cannula tubing behind the client's ears.
- C. Change the nasal cannula every 24 hr.
- D. Ensure the oxygen tubing is free of kinks.
Correct Answer: D
Rationale: Kink-free tubing ensures proper oxygen delivery. Petroleum jelly risks aspiration, securing tubing varies, and cannula changes aren't daily.