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A nurse is reviewing the prescription for doxazosin with a client. Which of the following should be included in the teaching?
- A. Decrease caloric intake to prevent weight gain.
- B. Increase dietary fiber to alleviate constipation.
- C. Rise slowly when sitting up from bed.
- D. Take this medication in the morning.
Correct Answer: C
Rationale: The correct answer is C. Doxazosin can cause orthostatic hypotension, leading to dizziness and falls if the client rises quickly from a seated position. Instructing the client to rise slowly when sitting up from bed helps prevent these adverse effects. Choices A, B, and D are incorrect because doxazosin does not directly relate to caloric intake, dietary fiber, or a specific time of day for administration.
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A nurse is providing teaching to a client who has osteoporosis about preventing fractures. Which of the following instructions should the nurse include?
- A. Increase your intake of calcium-rich foods.
- B. Avoid weight-bearing exercises.
- C. Perform weight-bearing exercises regularly.
- D. Avoid taking calcium supplements.
Correct Answer: C
Rationale: The correct instruction the nurse should include is to perform weight-bearing exercises regularly. Weight-bearing exercises help maintain bone density and reduce the risk of fractures in clients with osteoporosis. Increasing intake of calcium-rich foods (Choice A) is also beneficial for bone health. Avoiding weight-bearing exercises (Choice B) is incorrect as these exercises are essential for strengthening bones. Avoiding calcium supplements (Choice D) may not be necessary if the client's dietary intake is inadequate.
What is the most important assessment for a patient with suspected pneumonia?
- A. Monitor lung sounds
- B. Check oxygen saturation
- C. Assess for cough
- D. Assess for fever
Correct Answer: A
Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.
A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 118/76 mm Hg
- B. Heart rate of 88/min
- C. Urinary output of 30 mL/hr
- D. Hematocrit 42%
Correct Answer: B
Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.
A client with osteoporosis needs to increase calcium intake. Which of the following foods should be recommended by the nurse?
- A. Carrots
- B. Broccoli
- C. Chicken
- D. Bananas
Correct Answer: B
Rationale: The correct answer is B: Broccoli. Broccoli is rich in calcium and is a suitable food to recommend to clients with osteoporosis to increase their calcium intake. Carrots, chicken, and bananas are not as high in calcium content compared to broccoli and therefore not the most appropriate choices for increasing calcium intake in clients with osteoporosis.
If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct Answer: A
Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.