Nokea
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to 'see old buddies.' The nurse understands that the client's behaviors are warning signs to indicate that the client may be
- A. Headed for relapse
- B. Feeling hopeless
- C. Approaching recovery
- D. In need of increased socialization
Correct Answer: A
Rationale: Headed for relapse. These behaviors suggest a return to risky environments and habits, indicating potential relapse.
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The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I have muscle cramps.
- D. I take my medication with food.
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose level of 180 mg/dL.
- B. Temperature of 100.4°F (38°C).
- C. Weight gain of 1 kg in 24 hours.
- D. Potassium level of 3.8 mEq/L.
Correct Answer: B
Rationale: A temperature of 100.4°F suggests infection, a serious complication in TPN due to catheter-related bloodstream infections. Options A, C, and D are less urgent: hyperglycemia is common and manageable, rapid weight gain may indicate fluid overload, and potassium 3.8 mEq/L is normal.
A client with a necrotizing spider bite is to perform his own dressing changes at home.
The nurse is aware that which of the following statements, if made by the client, indicates a correct understanding of aseptic technique?
- A. I need to buy sterile gloves to redress this wound.'
- B. I should wash my hands before redressing my wound.'
- C. I should keep the wound covered at all times.'
- D. I should use an over-the-counter antimicrobial ointment.'
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-indicates understanding of asepsis, whose hallmark is handwashing (3) is not possible to carry out (4) should use only the prescribed medications on the wound
At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. The nurse should
- A. advise the client to decrease intake of fatty foods.
- B. schedule the client for a follow-up clinic visit in one month.
- C. inform the client that the cholesterol level is within normal limits.
- D. report the finding to the physician immediately.
Correct Answer: A
Rationale: A cholesterol level of 200 mg/dL is borderline high; reducing fatty foods is appropriate. Options B, C, and D are less immediate or incorrect.
The nurse is caring for clients in the student health center.
- A. What is the best response by the nurse to a client whose boyfriend Test ed positive for hepatitis B?
- B. That must have been a real shock to you.'
- C. You should be Test ed for hepatitis B.'
- D. You’ll receive the hepatitis B immune globulin (HBIG).'
- E. Have you had unprotected sex with your boyfriend?'
Correct Answer: D
Rationale: The nurse should first assess the client’s exposure risk, as hepatitis B is transmitted through sexual contact or parenteral routes. Asking about unprotected sex determines the need for Test ing or prophylaxis. Empathizing, recommending Test ing, or discussing HBIG are secondary to assessing exposure.