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A nurse is reinforcing teaching with a client who is scheduled for an exercise stress test. Which of the following instructions should the nurse include?
- A. Eat a large meal before the test.
- B. Wear comfortable shoes.
- C. Take a sedative before the test.
- D. Avoid drinking water during the test.
Correct Answer: B
Rationale: Wearing comfortable shoes ensures safety and ease during the physical activity required for an exercise stress test.
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A nurse is caring for a client who has a new prescription for varenicline. Which of the following adverse effects should the nurse monitor for?
- A. Mood changes
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Varenicline, used for smoking cessation, can cause mood changes, including depression or agitation, requiring monitoring.
A nurse is caring for a client who has a new prescription for trazodone. Which of the following adverse effects should the nurse monitor for?
- A. Drowsiness
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Trazodone, an antidepressant, commonly causes drowsiness, which can affect safety and coordination.
A nurse is reinforcing teaching with a client who is scheduled for a tilt-table test. Which of the following instructions should the nurse include?
- A. Fast for 4 hours before the test.
- B. Wear tight-fitting clothing.
- C. Take a sedative before the test.
- D. Avoid drinking fluids during the test.
Correct Answer: A
Rationale: Fasting for 4 hours before a tilt-table test reduces the risk of nausea or vomiting during positional changes.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
- A. Check the tube cuff pressure every 8 hours.
- B. Suction the tube every 4 hours.
- C. Reposition the tube every 12 hours.
- D. Clean the tube with alcohol-based solution.
Correct Answer: A
Rationale: Checking the tube cuff pressure every 8 hours ensures it remains within a safe range to prevent tracheal damage or air leaks.
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- A. Anaphylactic
- B. Acute hemolytic
- C. Febrile
- D. Circulatory overload
Correct Answer: A
Rationale: An anaphylactic reaction is correct. Symptoms such as urticaria (hives) and wheezing indicate a severe allergic reaction, which can progress to anaphylaxis. This reaction is caused by a hypersensitivity to plasma proteins in the transfused blood and requires immediate intervention, including stopping the transfusion and administering epinephrine.