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A nurse is reinforcing teaching with a client who has a new prescription for metformin. Which of the following statements should the nurse include?
- A. Take this medication on an empty stomach.
- B. You might have a metallic taste while taking this medication.
- C. You need to limit your protein intake.
- D. You should stop taking this medication if you feel shaky.
Correct Answer: B
Rationale: Metformin can cause a metallic taste, a side effect to anticipate. It's taken with meals, protein limits aren't needed, and shakiness requires glucose, not stopping.
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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 caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take to prevent infection?
- A. Encourage the client to avoid fresh fruits and vegetables.
- B. Administer prophylactic antibiotics daily.
- C. Monitor the client's white blood cell count regularly.
- D. Instruct the client to avoid crowded places.
Correct Answer: C
Rationale: Monitoring WBC counts detects neutropenia early, guiding infection prevention. Fresh produce is safe if washed, antibiotics aren't routine, and avoiding crowds is secondary.
A nurse is reinforcing teaching with a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?
- A. You can take this medication with or without food.
- B. You should avoid eating citrus fruits.
- C. You need to increase your intake of calcium.
- D. You should take this medication at bedtime.
Correct Answer: A
Rationale: Clopidogrel's administration is flexible with food, enhancing compliance. Citrus, calcium, or bedtime dosing aren't specific requirements.
A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following findings should the nurse report to the provider?
- A. The client reports chest discomfort.
- B. The client's temperature is 38.4°C (101.1°F).
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/80 mm Hg.
Correct Answer: B
Rationale: A temperature of 38.4°C suggests infection, requiring reporting. Chest discomfort, minimal drainage, and normal BP are expected or less urgent.
A nurse is caring for a client who is receiving IV vancomycin. Which of the following actions should the nurse take?
- A. Infuse the medication over 30 min.
- B. Monitor the client for tinnitus.
- C. Administer the medication with an antihistamine.
- D. Check the client's blood pressure every 4 hr.
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, so monitoring for tinnitus is essential. It's infused over 60-90 minutes, antihistamines aren't needed, and blood pressure checks aren't specific to vancomycin.