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A nurse is reinforcing teaching with a client who has a new prescription for sertraline. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication at bedtime.
- B. I might need to wait a few weeks to feel better.
- C. I can stop taking this medication if I feel sleepy.
- D. I should avoid drinking water after taking this medication.
Correct Answer: B
Rationale: Sertraline's effects take weeks to manifest, showing understanding. Timing is flexible, sleepiness doesn't warrant stopping, and water intake is unaffected.
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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 caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if a transfusion reaction is suspected?
- A. Increase the infusion rate.
- B. Administer diphenhydramine.
- C. Stop the transfusion.
- D. Elevate the client's legs.
Correct Answer: C
Rationale: Stopping the transfusion prevents further reaction. Increasing the rate worsens it, diphenhydramine is secondary, and leg elevation is unrelated.
A nurse is caring for a client who is receiving magnesium sulfate IV for preeclampsia. Which of the following findings indicates the medication is effective?
- A. Increased blood pressure
- B. Decreased respiratory rate
- C. Increased urine output
- D. Decreased deep tendon reflexes
Correct Answer: C
Rationale: Magnesium sulfate promotes diuresis, so increased urine output indicates effectiveness in managing fluid overload in preeclampsia.
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 reinforcing teaching with a client who has a new prescription for lisinopril. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I might need to check my blood pressure regularly.
- C. I can stop taking this medication if I feel better.
- D. I should avoid getting up quickly from sitting.
Correct Answer: B,D
Rationale: Lisinopril requires blood pressure monitoring and caution with position changes due to hypotension risk. Food isn't required, and stopping abruptly is unsafe.