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A nurse is reinforcing teaching with a client who has a new prescription for sertraline. Which of the following statements should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience insomnia while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You should expect immediate improvement in your symptoms.
Correct Answer: B
Rationale: Sertraline can cause insomnia, a key side effect to anticipate. It's taken flexibly, caffeine isn't restricted, and effects take weeks.
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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.
A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent phlebitis?
- A. Change the IV site every 72 to 96 hr.
- B. Massage the IV site gently every 4 hr.
- C. Apply a cold compress to the IV site.
- D. Use a large-gauge catheter for fluid administration.
Correct Answer: A
Rationale: Changing the IV site every 72-96 hours reduces infection and phlebitis risk. Massaging, cold compresses, or large catheters don't prevent phlebitis.
A nurse is caring for a client who is postoperative following a prostatectomy. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 2 hr.
- B. Instruct the client to resume a high-fiber diet immediately.
- C. Apply a cold pack to the perineal area.
- D. Encourage the client to sit for prolonged periods.
Correct Answer: A
Rationale: Monitoring urine output detects complications like obstruction. High-fiber diets resume gradually, cold packs aren't standard, and prolonged sitting risks discomfort.
The nurse is reviewing the medical record of a client who has a new prescription for zolpidem. Which of the following findings should the nurse identify as a potential contraindication for this medication?
- A. History of migraines
- B. Current use of sertraline
- C. Seasonal allergies
- D. History of sleepwalking
Correct Answer: D
Rationale: Zolpidem can exacerbate sleepwalking, making it a contraindication. Migraines, sertraline, or allergies don't pose significant risks with zolpidem.
A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take?
- A. Encourage the client to perform arm exercises on the affected side.
- B. Instruct the client to keep the affected arm dependent.
- C. Apply a cold pack to the surgical site every 2 hr.
- D. Administer a diuretic to reduce arm swelling.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and promote mobility. Dependent positioning worsens swelling, cold packs aren't standard, and diuretics aren't routine.