Nokea
Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
- A. Sedative hypnotics are effective analgesics
- B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
- C. Caffeine beverages can increase the effect of sedative hypnotics
- D. Avoidance of excessive exercise and high temperature is recommended
Correct Answer: B
Rationale: The correct answer is B. Alprazolam should not be stopped abruptly as it can cause rebound insomnia and nightmares; gradual tapering is necessary. Choice A is incorrect as sedative hypnotics are not primarily used as analgesics. Choice C is incorrect as caffeine can decrease the effects of sedative hypnotics rather than increase them. Choice D is incorrect as there is no specific recommendation to avoid excessive exercise or high temperature related to alprazolam use.
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A healthcare professional is preparing to administer an enteral feeding via an established NG tube. Which option is not part of the sequence the healthcare professional should follow to initiate the feeding?
- A. Verify tube placement
- B. Check the residual feeding contents
- C. Administer the feeding
- D. Limit protein intake
Correct Answer: D
Rationale: The correct sequence for initiating enteral feeding includes verifying tube placement to ensure safety, checking the residual feeding contents to prevent complications, and then administering the feeding. Limiting protein intake is not a step in the sequence for initiating enteral feeding. Protein intake may be adjusted based on the patient's specific nutritional needs, but it is not a part of the immediate sequence for initiating the feeding. Therefore, option D is the correct answer. Options A, B, and C are essential steps to ensure the safe and effective administration of enteral feeding.
The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is
- A. Heart rate
- B. Pedal pulses
- C. Lung sounds
- D. Pupil responses
Correct Answer: D
Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.
A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?
- A. Monitor the client's temperature
- B. Assess the client's pain level
- C. Check the intravenous (IV) site for signs of phlebitis
- D. Monitor the client's respiratory status
Correct Answer: C
Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.
A nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?
- A. Increase fluid intake by drinking bottled water.
- B. A salad bar is a healthy choice when dining out.
- C. Soft-boiled eggs are an appropriate source of protein.
- D. Eating at buffets is a good choice to increase caloric intake.
Correct Answer: A
Rationale: Clients with neutropenia should avoid foods that may be contaminated to prevent infections. Increasing fluid intake is important to stay hydrated, but it's crucial to use safe sources like bottled water to reduce the risk of infection. Choices B, C, and D are not appropriate for a client with neutropenia. Salad bars may contain raw or unwashed produce, soft-boiled eggs may carry a risk of contamination, and buffets may have food items that are not recommended for someone with neutropenia.
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?
- A. Administer oxygen therapy
- B. Encourage the client to perform deep breathing exercises
- C. Raise the head of the bed
- D. Check the client's oxygen saturation level
Correct Answer: D
Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.