Nokea
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client had a hemorrhoidectomy 1 year ago.
- B. The client takes ibuprofen for headaches.
- C. The client has a history of breast cancer.
- D. The client consumed citrus juice 3 days before the test
Correct Answer: B
Rationale: Ibuprofen, an NSAID, can cause GI irritation and bleeding, leading to a false-positive fecal occult blood test. The other factors are unlikely to affect the result directly.
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A nurse is reinforcing teaching about liquid iron supplements with a client who has anemia. Which of the following information should the nurse include in the teaching?
- A. Take iron supplements between meals for maximum absorption.
- B. Mix iron supplements with milk to prevent staining of the teeth.
- C. Reduce gastric distress by taking iron supplements with an antacid.
- D. Check for orange-colored stools after 4 days of treatment.
Correct Answer: A
Rationale: Iron supplements treat anemia by boosting hemoglobin, but absorption and side effects guide administration. Option A is correct taking iron between meals maximizes absorption since food, especially calcium or fiber, can bind iron, reducing bioavailability. Gastric acid enhances uptake, so an empty stomach is ideal, though some tolerate it with a small snack if irritation occurs. Option B is wrong milk's calcium inhibits absorption and doesn't prevent teeth staining (diluting in juice does). Option C is incorrect antacids raise stomach pH, decreasing iron absorption, and may worsen deficiency. Option D is false iron typically causes black, not orange, stools due to unabsorbed iron oxidation; orange stools could signal another issue. Teaching about between-meal dosing empowers the client to optimize therapy, manage side effects (like constipation or nausea), and monitor for expected changes (e.g., darker stools), ensuring effective anemia treatment.
A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Peripheral edema
- C. Decreased respirations
- D. Absent bowel sounds
Correct Answer: D
Rationale: Absent bowel sounds indicate paralytic ileus, a common finding in peritonitis due to inflammation. Polyuria, edema, and decreased respirations are not typical.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Medical History
Today, 0700:
Admitting Diagnosis: Heart Failure
Past medical history of heart failure, coronary artery disease, sleep apnea
Client reports diarrhea, dry mouth, and unusual thirst for the past three days
A nurse is assisting in the care of a male client who has a new prescription for furosemide. Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide?
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. Client verbal report
- E. BUN
Correct Answer: A
Rationale: Furosemide, a loop diuretic, treats heart failure but depletes potassium, risking hypokalemia. A low potassium level (e.g., <3.5 mEq/L) contraindicates its use hypokalemia causes arrhythmias, especially with heart failure's cardiac strain, per pharmacology standards. Blood pressure matters hypotension may worsen with diuresis but isn't a direct contraindication unless extreme. Digoxin use heightens hypokalemia risk (enhancing toxicity), but potassium level drives the decision. The client's report of diarrhea and thirst suggests dehydration, a caution, not a strict contraindication. Low potassium demands correction (e.g., supplements) before furosemide, preventing lethal complications like ventricular fibrillation, making it the critical finding to identify.
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
- A. Jaundice
- B. Muscle rigidity
- C. Weight loss
- D. Easily bruised
Correct Answer: D
Rationale: Easy bruising is expected in Cushing's syndrome due to excess cortisol thinning the skin and weakening blood vessels. Jaundice, rigidity, and weight loss are not typical.
A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?
- A. Atorvastatin
- B. Sildenafil
- C. Omeprazole
- D. Metformin
- E. Aspirin
- F. Ibuprofen
- G. Warfarin
Correct Answer: B
Rationale: Sildenafil (Viagra) with nitroglycerin can cause severe hypotension; other meds don't interact significantly.