Nokea
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
- A. Document the output and vital signs
- B. Draw blood for hemoglobin and hematocrit
- C. Lower the head of the bed
- D. Notify the registered nurse
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.
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An older adult is diagnosed with open-angle glaucoma. Which comment by the client indicates understanding of the management of the condition?
- A. I will take the eye drops every day.'
- B. I hope the medicine works and I am cured soon.'
- C. My wife is worried that I may give her glaucoma.'
- D. How long will it be before I need surgery?'
Correct Answer: A
Rationale: Daily eye drops control intraocular pressure in open-angle glaucoma, a chronic condition, indicating understanding, unlike expecting a cure, contagiousness, or immediate surgery.
The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply.
- A. Encourage the client to speak slowly and pause to take deep breaths periodically
- B. Identify and promote the client's capabilities and strengths throughout the sessions
- C. Provide client teaching during times of day when the client has the most energy
- D. Reserve discussion of important or complex teaching for the client's caregiver
- E. Schedule teaching sessions at times with low risk of rushing or interruptions
Correct Answer: A,B,C,E
Rationale: Speaking slowly aids clarity, promoting strengths builds confidence, teaching during high-energy times optimizes learning, and uninterrupted sessions enhance focus. Complex teaching should include the client, not just the caregiver, to respect autonomy.
The nurse has reinforced teaching with a client who has anxiety and a new prescription for alprazolam. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can continue to take my prescribed muscle relaxant as needed.
- B. I can omit the medication on days when I do not feel anxious.
- C. I should eliminate aged cheese and processed meats from my diet.
- D. I will discontinue the medication and notify my health care provider if I become pregnant.
Correct Answer: D
Rationale: Alprazolam is a benzodiazepine, and its use during pregnancy can pose risks to the fetus. Discontinuing and notifying the provider is critical. Muscle relaxants may enhance sedation, skipping doses disrupts therapeutic levels, and dietary restrictions like avoiding tyramine are not required for alprazolam.
The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?
- A. These decisions are challenging. Tell me about your spouse's beliefs regarding end-of-life care.
- B. You seem overwhelmed. I will ask the chaplain to speak with you about available options.
- C. I find it helpful to investigate all options. I will get you a pamphlet about hospice services.
- D. I had to make a similar decision when my spouse was ill. Do what feels best for you.
Correct Answer: A
Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.
The client is receiving furosemide (Lasix) 80 mgm. Which is a sign of a possible complication of the administration of furosemide?
- A. Tachycardia
- B. Hypertension
- C. Polyuria
- D. Eupnea
Correct Answer: A
Rationale: Furosemide is a loop diuretic that can cause electrolyte imbalances, such as hypokalemia, which may lead to tachycardia. Hypertension is not a common complication; polyuria is an expected effect, not a complication; and eupnea (normal breathing) is unrelated.