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A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the following questions should the nurse include in the assessment? Which question should the nurse ask for migraine assessment?
- A. Have you experienced any nausea or vomiting with your headache?
- B. Are the lights in this room bothering you?
- C. Have you noticed any confusion or clouded thinking?
- D. Did you feel weak before the headache started or do you feel weak now?
Correct Answer: A
Rationale: The correct answer is A: "Have you experienced any nausea or vomiting with your headache?" This question is crucial in assessing migraines as nausea and vomiting are common accompanying symptoms. Nausea and vomiting are associated with activation of the autonomic nervous system during migraines. The other options are not as directly related to migraines. B is more relevant to light sensitivity in migraines, C is more related to confusion or cognitive symptoms, and D is more focused on weakness, which are not typically primary symptoms of migraines.
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A nurse is caring for a patient who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider? Which finding post-cholecystectomy should the nurse report?
- A. Clay-colored stools
- B. Mild abdominal pain
- C. Nausea
- D. Fatigue
Correct Answer: A
Rationale: Correct Answer: A: Clay-colored stools
Rationale: Clay-colored stools can indicate a potential issue with bile flow, which is crucial post-cholecystectomy. Absence of bile in the stool may suggest a blocked bile duct, leading to complications like jaundice or infection. This finding should be reported promptly for further evaluation and management.
Summary of other choices:
- B: Mild abdominal pain is common post-surgery and can be managed with pain medications.
- C: Nausea is also expected after surgery and can be managed with antiemetics.
- D: Fatigue is a common postoperative symptom and may improve with rest and proper nutrition.
A nurse is caring for a patient who has a new prescription for fluconazole. Which of the following instructions should the nurse include? What instructions should the nurse include for fluconazole?
- A. Take the medication with food.
- B. Report any abdominal pain.
- C. Avoid driving for 24 hours.
- D. Take the medication at bedtime.
Correct Answer: B
Rationale: The correct answer is B: Report any abdominal pain. This is important because fluconazole can cause gastrointestinal side effects such as abdominal pain, nausea, and diarrhea. Prompt reporting of abdominal pain can help monitor for potential complications like liver toxicity. Choice A is incorrect as fluconazole can be taken with or without food. Choice C is incorrect as fluconazole does not typically impair driving ability. Choice D is incorrect as fluconazole can be taken at any time of the day.
A nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The available amount is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? How many clonidine tablets should the nurse administer?
Correct Answer: 3
Rationale: Correct Answer: 3
Rationale: To calculate the number of tablets needed, divide the total dose needed (0.3 mg) by the dose per tablet (0.1 mg). 0.3 mg ÷ 0.1 mg = 3 tablets. Therefore, the nurse should administer 3 tablets per dose.
Summary:
A: Incorrect - Not the correct number of tablets based on the dosage calculation.
B: Incorrect - Not the correct number of tablets based on the dosage calculation.
C: Incorrect - Not the correct number of tablets based on the dosage calculation.
D: Incorrect - Not the correct number of tablets based on the dosage calculation.
E: Incorrect - Not the correct number of tablets based on the dosage calculation.
F: Incorrect - Not the correct number of tablets based on the dosage calculation.
G: Incorrect - Not the correct number of tablets based on the dosage calculation.
A nurse is caring for a patient who is receiving IV fluids. The nurse notes that the IV site is red, warm, and painful. Which of the following actions should the nurse take first? What should the nurse do first for IV site issues?
- A. Slow the infusion rate.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: The correct action for the nurse to take first is to discontinue the IV line (choice C). This is essential to prevent further complications such as infection or infiltration. Discontinuing the IV line will stop the source of the redness, warmth, and pain at the IV site. Slowing the infusion rate (choice A) would not address the underlying issue and could potentially worsen the situation. Applying a warm compress (choice B) could also exacerbate the symptoms if there is an infection. Notifying the provider (choice D) is important but should come after the immediate action of discontinuing the IV line to address the IV site issues promptly.
A nurse is caring for a patient who has a new prescription for lisinopril. Which of the following laboratory values should the nurse monitor? Which lab value should the nurse monitor for lisinopril?
- A. Serum potassium
- B. Serum calcium
- C. Serum magnesium
- D. Serum chloride
Correct Answer: A
Rationale: The nurse should monitor serum potassium levels because lisinopril, an ACE inhibitor, can cause potassium retention leading to hyperkalemia. Hyperkalemia can result in serious cardiac complications. Monitoring potassium levels allows timely intervention if levels become elevated. Serum calcium, magnesium, and chloride are not typically affected by lisinopril, making choices B, C, and D incorrect. The correct answer, A, is crucial for patient safety and reflects the physiological impact of lisinopril on potassium levels.