Nokea
A nursing assistant reports to the RN that a patient with anemia is complaining of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?
- A. Listen to the patient's breath sounds and report back to me.'
- B. Set up the patient's lunch tray.'
- C. Obtain a diet history from the patient.'
- D. Instruct the patient to balance rest and activity.'
Correct Answer: B
Rationale: standard, unchanging procedure; decrease cardiac workload
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The nurse is caring for a client with a history of depression who is receiving bupropion (Wellbutrin) 150 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a dry mouth.
- B. I feel restless sometimes.
- C. I think about ending my life.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of ending life indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on bupropion. Options
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are
- A. sedation as needed to prevent exhaustion
- B. antibiotic therapy for 10 to 14 days
- C. humidified air and increased oral fluids
- D. antihistamines to decrease allergic response
Correct Answer: C
Rationale: humidified air and increased oral fluids. The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.
The nurse is teaching a client with a new diagnosis of osteoarthritis about celecoxib (Celebrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any black, tarry stools
- C. Stop the medication if pain decreases
- D. Avoid regular joint exams
Correct Answer: B
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious celecoxib side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication may not be advised, and exams are needed.
The physician prescribes sulfisoxazole (Gantrisin) 2 g PO qid for a client. Which of the following instructions is MOST important for the nurse to include when teaching the client about this medication?
- A. Drink plenty of fluids.
- B. Wear sunscreen when outdoors.
- C. Eliminate dairy products from your diet.
- D. Take this medication with meals.
Correct Answer: A
Rationale: Sulfisoxazole can cause crystalluria; adequate fluid intake prevents kidney stones. Options B, C, and D are less critical or incorrect.
The nurse is planning care for a client who had surgery for an ileal conduit two days ago. It is MOST important for the nurse to take which of the following actions?
- A. Remove the appliance regularly and clean the skin with antiseptic solution.
- B. Apply a close-fitting drainage bag to the stoma.
- C. Massage the skin around the stoma with an emollient.
- D. Expose the area around the stoma to air twice a day.
Correct Answer: B
Rationale: A close-fitting drainage bag prevents urine leakage, protecting skin integrity post-ileal conduit. Options A, C, and D risk skin irritation or bag adhesion issues.