Nokea
An adult who has newly diagnosed angina has been prescribed sublingual nitroglycerin. What should be included in the nurse's teaching about the medication? Select all that apply.
- A. Put the tablets under your tongue and let them dissolve.
- B. Keep the tablets in a dark glass container.
- C. You can take one tablet, and if you still have pain, you can take another tablet in 10 minutes.
- D. Be sure to take nitroglycerin while you are standing up.
- E. You may get a headache shortly after you take the medication,
- F. If your tongue tingles spit out the tablet.
Correct Answer: A,B,E
Rationale: Sublingual nitroglycerin is dissolved under the tongue, stored in dark glass to maintain potency, and may cause headaches as a side effect.
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Diphenoxylate hydrochloride with atropine sulfate (Lomotil) is prescribed for a client. The nurse knows that the drug is prescribed for which of these problems the client has?
- A. Diarrhea
- B. Hypertension
- C. Depression
- D. Tachycardia
Correct Answer: A
Rationale: Lomotil is an antidiarrheal, slowing intestinal motility to reduce diarrhea.
During the immediate postoperative period after a colostomy, which stoma appearance requires the licensed practical nurse to contact the supervising registered nurse immediately?
- A. Brick red with slight moisture
- B. Dusky moderate edema
- C. Pink with slight oozing of blood
- D. Red with no stool produced
Correct Answer: B
Rationale: A dusky stoma (B) indicates ischemia, requiring immediate reporting. Brick red (A), pink with oozing (C), and no stool (D) are normal post-colostomy findings.
The nurse is instructing the client with a fractured femur in crutch walking. When instructing the client in the best method of manipulating stairs, the nurse should tell the client to:
- A. Start up the stairs with the crutches first.
- B. Start up the stairs with the unaffected leg first.
- C. Use the affected leg to move up the stairs first.
- D. Use the unaffected leg to move down the stairs.
Correct Answer: B
Rationale: For ascending stairs, lead with the unaffected leg to bear weight, followed by crutches and affected leg. This ensures stability and safety.
A 13-month-old child is admitted to the pediatric unit with diarrhea and vomiting. The mother tells the nurse that she is worried because her son does not yet walk. She says her other children walked at eight and nine months and asks what could be wrong with this child. How should the nurse respond?
- A. All babies are different. It is not abnormal that the baby is not yet walking.'
- B. The baby should be walking. I'll let the doctor know he is behind developmentally.'
- C. Your son is probably enjoying being the baby and is not eager to grow up and walk.'
- D. Walking requires complex coordination. Your son is probably just a little slow to develop this. Don't worry.'
Correct Answer: A
Rationale: Walking typically occurs between 9-18 months; at 13 months, not walking is within normal variation, reassuring the mother without dismissing concerns.
The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate?
- A. Assisting the parents in signing Against Medical Advice (AMA) papers
- B. Discharging the child if parents have power of attorney papers
- C. Notifying the hospital administration about the situation
- D. Reassuring the parents that their decision will be respected under the principle of autonomy
Correct Answer: C
Rationale: A 4-year-old with suspected meningitis requires urgent treatment. Notifying administration (C) ensures legal and ethical intervention to protect the child. AMA (A), power of attorney (B), or respecting autonomy (D) are inappropriate for a minor.