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Diltiazem (Cardizem) 90 mg qid is prescribed for an adult who has angina. Which statement by the client indicates a need for further instruction?
- A. I will take the pills before meals and at bedtime.
- B. I will call my physician if the pain gets worse than it has been.
- C. If my heart rate is less than 70, I will not take the pill.
- D. I will get up slowly when I stand up.
Correct Answer: C
Rationale: Diltiazem is not typically withheld based on heart rate alone unless specified; this indicates a need for clarification on administration instructions.
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The nurse is discussing child safety with the parents of a 12-month-old child who is just beginning to walk. Which statement by the parents indicates a need for further instruction?
- A. Our swimming pool is fenced in with a lock on the gate.'
- B. We have installed childproof gates at the top and bottom of our stairs.'
- C. We need to lower the mattress in our child's crib.'
- D. When we are unable to supervise, we can put our child in a mobile walker.'
Correct Answer: D
Rationale: Using a mobile walker is unsafe for a walking 12-month-old due to fall and injury risks, requiring further teaching. Fenced pools , stair gates , and lowered crib mattresses are appropriate safety measures.
The nurse is caring for a client who is in the first stage of labor and is reporting intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which of the following actions should the nurse take?
- A. Place the client in the supine position
- B. Apply counterpressure to the client's sacrum during contractions
- C. Encourage the client to remain in bed
- D. Request that the nurse anesthetist administer epidural anesthesia
Correct Answer: B
Rationale: For back pain in labor with a right occiput posterior position, applying counterpressure to the sacrum relieves discomfort. Supine position worsens pain, bed rest limits mobility, and epidural is not the first intervention.
The client has contact dermatitis from poison ivy. Which statement, if made by the client, indicates that he understands how to care for his condition?
- A. A hot bath should make the itching go away.'
- B. I will use a good strong soap when I wash the affected areas.'
- C. A cool wet cloth to the area should help.'
- D. Wearing wool socks will help my itchy feet.'
Correct Answer: C
Rationale: A cool wet cloth soothes itching and inflammation in contact dermatitis. Hot baths, strong soaps, or wool exacerbate irritation.
The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?
- A. Apply suprapubic pressure
- B. Perform Leopold maneuvers
- C. Perform the McRoberts maneuver
- D. Assist the client to the knee-chest position
Correct Answer: D
Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
- A. Temperature of 99.5 degrees Fahrenheit with painful urination
- B. An open, reddened wound on the heel
- C. Insomnia and daytime fatigue
- D. Nausea with 2 episodes of vomiting
Correct Answer: B
Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.