Nokea
A nurse is teaching a client who has a new prescription for alendronate. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication at bedtime to prevent drowsiness.
- B. I should take this medication with a full glass of water before breakfast.
- C. I should avoid taking this medication with dairy products.
- D. I should remain upright for at least 30 minutes after taking this medication.
Correct Answer: B
Rationale: The correct answer is B. Alendronate should be taken with a full glass of water before breakfast to prevent esophageal irritation and improve absorption. Choice A is incorrect as alendronate is not associated with causing drowsiness. Choice C is incorrect because alendronate can be taken with or without food, so avoiding dairy products is not necessary. Choice D is incorrect as the recommended time to remain upright after taking alendronate is 30 minutes to 1 hour, not just 30 minutes.
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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. FHR baseline 170/min.
- C. Early decelerations in the FHR.
- D. Temperature 37.4°C (99.3°F).
Correct Answer: B
Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.
A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?
- A. Potassium 5.0 mEq/L
- B. Blood pressure 136/84 mm Hg
- C. Sodium 140 mEq/L
- D. Calcium 9.5 mg/dL
Correct Answer: A
Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.
A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?
- A. Dehydration is treated with calcium supplements
- B. Dehydration can increase the risk of preterm labor
- C. Dehydration can increase gastroesophageal reflux
- D. Dehydration is caused by a decreased hemoglobin and hematocrit
Correct Answer: B
Rationale: The correct statement the nurse should make is that dehydration can increase the risk of preterm labor. Dehydration reduces amniotic fluid and uterine blood flow, potentially leading to preterm contractions. Choice A is incorrect because dehydration is not treated with calcium supplements but rather with adequate fluid intake. Choice C is incorrect as dehydration does not directly increase gastroesophageal reflux. Choice D is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by insufficient fluid intake or excessive fluid loss.
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?
- A. Shave hairy areas of skin prior to application.
- B. Wear gloves to apply the patch to the client's skin.
- C. Apply the patch within 1 hr of removing it from the protective pouch.
- D. Remove the previous patch and place it in a tissue.
Correct Answer: B
Rationale: The correct answer is to wear gloves to apply the patch to the client's skin. This action ensures that the nurse does not absorb any medication through their own skin, promoting safety. Choice A is incorrect because shaving is not necessary and could irritate the skin. Choice C is incorrect because transdermal patches should be applied immediately after removal from the protective pouch to maintain their efficacy. Choice D is incorrect because used patches should be folded and discarded safely according to facility protocols.
A nurse is teaching a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?
- A. "You should expect to feel an improvement in your symptoms within 1 week."
- B. "You may experience weight gain while taking this medication."
- C. "You should take this medication in the morning to prevent insomnia."
- D. "You should stop taking this medication if you experience dry mouth."
Correct Answer: B
Rationale: The correct statement the nurse should include is that the client may experience weight gain while taking fluoxetine. Weight gain is a common side effect of fluoxetine, and patients should be informed about this potential issue. Stating that the client should expect improvement in symptoms within 1 week (Choice A) is incorrect as fluoxetine may take a few weeks to have a noticeable effect. Taking the medication in the morning to prevent insomnia (Choice C) is not necessary since fluoxetine can be taken at any time of the day. Instructing the client to stop taking the medication if experiencing dry mouth (Choice D) is misleading, as dry mouth is a common but usually not serious side effect of fluoxetine.