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Cimetidine (Tagamet) may also be used to treat hiatal hernia. The nurse should understand that this drug is used to prevent which of the following?
- A. Esophageal reflux.
- B. Dysphagia.
- C. Esophagitis.
- D. Ulcer formation.
Correct Answer: C
Rationale: Cimetidine, an H2-receptor antagonist, reduces gastric acid production, helping to prevent esophagitis caused by acid reflux in hiatal hernia.
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The client has had a cataract removed. The nurse's discharge instructions should include which of the following?
- A. Keep the head aligned straight.
- B. Utilize bright lights in the home.
- C. Use an eye shield at night.
- D. Change the eye patch as needed.
Correct Answer: C
Rationale: Using an eye shield at night prevents rubbing the eye. The head should be turned to the side to scan the entire visual field to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The surgeon changes the eye patch on the second postoperative day.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) best reflects the client's symptoms of tiring rapidly due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported.
A client with malignant pleural effusions is complaining of dyspnea and chest pain. Place the following interventions that the nurse should perform in the correct order of priority.
- A. Administer morphine sulfate 2 mg I.V.
- B. Apply oxygen at 2 L via nasal cannula.
- C. Educate the client in anticipation of a thoracentesis.
- D. Coach the client on deep breathing exercise.
Correct Answer: B,A,C,D
Rationale: Oxygen (B) addresses immediate hypoxia, morphine (A) relieves pain and dyspnea, education for thoracentesis (C) prepares for definitive treatment, and deep breathing (D) supports respiratory function.
The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?
- A. Low-pressure alarm
- B. Increased blood glucose
- C. Diminished lung sounds
- D. Hemoglobinuria
Correct Answer: D
Rationale: Hemoglobinuria (blood in the urine) is a hallmark of a hemolytic transfusion reaction, indicating red blood cell destruction. Low-pressure alarms relate to ventilator issues, increased glucose is unrelated, and diminished lung sounds may suggest other issues but not specifically transfusion reactions.
Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease?
- A. 45-year-old mother.
- B. 17-year-old daughter.
- C. 8-year-old son.
- D. 76-year-old grandmother.
Correct Answer: D
Rationale: The elderly (76-year-old grandmother) are at highest risk due to weakened immune systems, increasing susceptibility to tuberculosis infection. Children and younger adults are less vulnerable unless immunocompromised.