Nokea
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish her supply every three months.
- B. Take one every 15 minutes if pain occurs.
- C. Leave the medication in the brown bottle.
- D. Crush the medication and take it with water.
Correct Answer: C
Rationale: The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.
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The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse?
- A. Female client with a fractured pelvis who is 4 months pregnant
- B. Female client with cytomegalovirus pneumonia
- C. Male client with an open bowel resection with a Foley catheter
- D. Male client with history of Billroth II surgery who is septic
Correct Answer: A
Rationale: The OB nurse’s expertise in pregnancy care makes the pregnant client with a fractured pelvis (A) the best assignment, as it aligns with their skills in managing maternal-fetal health. Other clients (B, C, D) require general medical-surgical care unrelated to OB.
The nurse is reinforcing teaching of proper foot care to a client with diabetes mellitus. Which statement by the client indicates the need for further teaching?
- A. I will apply lanolin to my feet to prevent dry skin
- B. I will avoid applying a heating pad directly to my feet
- C. I will test the water with a thermometer before bathing
- D. I will wear sandals instead of sneakers to prevent moisture.
Correct Answer: D
Rationale: Sandals (D) expose feet to injury, increasing infection risk in diabetes. Lanolin (A), avoiding heating pads (B), and testing water (C) are correct to prevent skin breakdown and burns.
A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to
- A. maintain fluid and electrolyte balance
- B. manage post-operative pain
- C. ambulate the client within 1 hour of surgery
- D. control bladder spasms
Correct Answer: B
Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.
A 2-year old is hospitalized with gastroenteritis and dehydration. Which of the following methods is best for evaluating changes in skin turgor?
- A. Pinching the abdominal tissue while the client is supine
- B. Pinching the tissue of the forearm while the client is sitting
- C. Pressing the skin of the lower extremities while the client is supine
- D. Pinching the skin of the lower extremities while the client is sitting
Correct Answer: A
Rationale: Pinching abdominal tissue while supine is the best method to assess skin turgor in a dehydrated child, as it reflects hydration status accurately.
A client with emphysema comes for a routine follow-up visit. The nurse assisting with the initial assessment knows that which manifestations are characteristic of emphysema? Select all that apply.
- A. Barrel chest
- B. Bilateral coarse crackles
- C. Decreased activity tolerance
- D. Diminished breath sounds
- E. Increased sputum production
Correct Answer: A,C,D
Rationale: Emphysema causes air trapping, leading to barrel chest (A), reduced exercise capacity (C), and diminished breath sounds (D). Crackles (B) suggest fluid, and sputum (E) is more typical of chronic bronchitis.