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A nurse is reinforcing teaching with a client who has a new prescription for omeprazole. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You might need to take this medication for up to 8 weeks.
- C. Stop taking this medication if you experience heartburn.
- D. Take this medication with an antacid for best results.
Correct Answer: B
Rationale: Omeprazole may require 4-8 weeks for full effect in treating conditions like GERD. It's taken before meals, not bedtime, stopping for heartburn is incorrect, and antacids don't enhance it.
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A nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for lithium. Which of the following instructions should the nurse include in the teaching?
- A. Increase intake of foods high in potassium.
- B. Maintain a consistent sodium intake.
- C. Limit daily exercise to 30 min.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Consistent sodium intake prevents lithium toxicity or reduced efficacy. Potassium, exercise limits, or empty stomach administration aren't necessary.
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 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 mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse report to the provider?
- A. The client's oxygen saturation is 95%.
- B. The client's cuff pressure is 35 cm H2O.
- C. The client's respiratory rate is 16 breaths/min.
- D. The client's temperature is 37.1°C (98.8°F).
Correct Answer: B
Rationale: A cuff pressure of 35 cm H2O (above 20-30 cm H2O) risks tracheal damage, requiring reporting. Normal saturation, respiratory rate, and temperature are unremarkable.
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 to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water every 4 hr.
- B. Place the client in a supine position during feeding.
- C. Check for gastric residual volume every 4 hr.
- D. Keep the head of the bed elevated to at least 30 degrees.
Correct Answer: D
Rationale: Elevating the bed to 30-45 degrees reduces aspiration risk by promoting proper digestion. Flushing maintains patency, supine position increases risk, and residual checks monitor tolerance.