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A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?
- A. Refill the prescription every 12 months.
- B. Take a second tablet after 5 min for unrelieved chest pain.
- C. Swallow the tablet whole with a glass of water.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Taking a second dose after 5 minutes for unrelieved pain is standard protocol for nitroglycerin, which is taken sublingually, not swallowed, and stored at room temperature, refilled every 6 months.
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A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause involves hormonal shifts causing various symptoms, but priority follows clinical urgency. Urinary frequency stands out it could indicate a urinary tract infection, bladder dysfunction, or even a gynecologic issue like prolapse, all requiring prompt evaluation. Difficulty sleeping, hot flashes, and vaginal dryness are classic perimenopausal symptoms from estrogen decline, managed symptomatically unless severe. Frequency, however, suggests a potential complication beyond hormonal changes, possibly impacting renal or pelvic health. Using the ABCs or Maslow's hierarchy, urinary issues tie to elimination needs, outranking sleep or comfort concerns. Reporting this ensures timely diagnosis (e.g., urinalysis) and treatment, preventing progression to pyelonephritis or chronic conditions, making it the most pressing finding to escalate.
A nurse is reinforcing teaching about high-fiber foods with a client at a health fair. Which of the following foods should the nurse recommend as having the highest fiber content?
- A. 240 mL (8 oz) tomato juice
- B. 240 mL (8 oz) low-fat strawberry Greek yogurt
- C. 1 cup cooked peas
- D. 1 medium banana
Correct Answer: C
Rationale: Fiber content varies widely among foods, and cooked peas top this list. One cup of cooked peas offers about 8-9 grams of fiber, thanks to their legume properties, promoting bowel health and satiety. Tomato juice (8 oz) has roughly 1-2 grams mostly water, low in bulk. Low-fat strawberry Greek yogurt provides minimal fiber (<1 gram), as dairy lacks it naturally, despite added fruit. A medium banana has about 3 grams, decent but far below peas. Recommending peas educates the client on a nutrient-dense, high-fiber choice, aligning with dietary guidelines (e.g., 25-30 grams daily), supporting digestion, and preventing chronic diseases like diverticulosis, making it the best option to highlight.
A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?
- A. Instruct the client to tilt their head back to facilitate swallowing
- B. Encourage the client to use a straw.
- C. Provide oral care before meals.
- D. Schedule physical therapy directly before meals.
Correct Answer: C
Rationale: Oral care before meals removes debris and reduces aspiration risk in dysphagia. Tilting back worsens swallowing, straws may not be safe, and therapy timing isn't relevant.
A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the partner indicates an understanding of the teaching?
- A. I can take my partner outside of the room as long as they wear a mask.
- B. I will wash my hands as soon as I leave the room.
- C. I will wear a gown when I help my partner take a bath.
- D. I will reuse unsoiled gloves when I re-enter the room.
Correct Answer: B
Rationale: Hand washing upon leaving prevents MRSA spread, a key contact precaution. Masks don't suffice, gowns are needed for bathing, and gloves must be fresh each entry.
A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective?
- A. I continue to lose weight.
- B. I have less oily skin.
- C. I no longer feel nervous.
- D. I no longer take a stool softener.
- E. I feel more tired.
- F. My appetite has decreased.
- G. My heart rate is faster.
Correct Answer: C
Rationale: Reduced nervousness indicates propylthiouracil is controlling hyperthyroid symptoms like anxiety.