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A nurse is reinforcing teaching with a client who has a new prescription for venlafaxine. 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 have headaches while taking this medication.
- C. I need to avoid caffeine.
- D. I can expect my mood to improve right away.
Correct Answer: B
Rationale: Venlafaxine can cause headaches, showing understanding. Food enhances absorption, caffeine isn't restricted, and mood improvement takes weeks.
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A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Check the client's blood glucose levels regularly.
- B. Administer TPN through a peripheral IV line.
- C. Change the TPN bag every 48 hr.
- D. Monitor the client's blood pressure every 4 hr.
Correct Answer: A
Rationale: TPN's high glucose content requires regular blood glucose monitoring to prevent hyperglycemia. It's given centrally, bags change every 24 hours, and blood pressure isn't specific.
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Encourage the client to flex the knee every 2 hr.
- B. Apply a continuous passive motion machine as prescribed.
- C. Instruct the client to keep the leg in a dependent position.
- D. Administer a diuretic to reduce swelling.
Correct Answer: B
Rationale: A CPM machine promotes mobility and prevents stiffness as prescribed. Flexion timing varies, dependent positioning increases swelling, and diuretics aren't routine.
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching?
- A. You might experience weight loss while taking this medication.
- B. You should expect to have increased energy within a few days.
- C. You might feel drowsy, so avoid driving until you know how this medication affects you.
- D. You can stop taking this medication as soon as your symptoms improve.
Correct Answer: C
Rationale: Amitriptyline can cause drowsiness, so avoiding driving is prudent. Weight gain, not loss, is common, effects take weeks, and abrupt stopping risks relapse.
A nurse is caring for a client who is postoperative following a hysterectomy. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate as tolerated.
- B. Instruct the client to avoid deep breathing exercises.
- C. Apply a warm compress to the incision site.
- D. Administer a sedative every 4 hr.
Correct Answer: A
Rationale: Ambulation prevents complications like thromboembolism. Deep breathing aids recovery, warm compresses risk infection, and sedatives aren't routine.
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.