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The client diagnosed with essential hypertension calls the clinic and tells the nurse she needs something for the flu. Which information should the nurse tell the client?
- A. OTC medications for the flu should not be taken because of your hypertension.
- B. If OTC medications do not relieve symptoms within three (3) days, contact the HCP.
- C. Tell the client to ask the pharmacist to recommend an OTC medication for the flu.
- D. Make an appointment for the client to receive the influenza vaccine.
Correct Answer: B
Rationale: OTC flu medications (e.g., decongestants) may raise BP but can be used cautiously; persistent symptoms warrant HCP contact. Total avoidance, pharmacist reliance, or vaccines are less appropriate.
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A client with an aplastic sickle cell crisis is receiving a blood transfusion and begins to complain of 'feeling hot.' Almost immediately, the client begins to wheeze. What is the nurse's first action?
- A. Stop the blood infusion
- B. Notify the health care provider
- C. Take/record vital signs
- D. Send blood samples to lab
Correct Answer: A
Rationale: Stop the blood infusion. If a reaction of any type is suspected during administration of blood products, stop the infusion immediately, keep the line open with saline, notify the health care provider, monitor vital signs and other changes, and then send a blood sample to the lab.
A 17-year-old client has been recently diagnosed as having diabetes mellitus Type 1. Insulin is prescribed. The client asks why insulin can't be taken by mouth. What is the best answer for the nurse to give?
- A. Insulin is irritating to the stomach.
- B. Oral insulin is too rapidly absorbed.
- C. Gastric juices destroy insulin.
- D. You can take it by mouth when the acute phase is over.
Correct Answer: C
Rationale: Insulin is a protein destroyed by gastric enzymes, requiring injection for effective delivery.
The nurse is administering an otic drop to the 45-year-old client. Which procedure should the nurse implement when administering the drops?
- A. Place the drops when pulling the ear down and back.
- B. Place the drops when pulling the ear up and back.
- C. Place the drops in the lower conjunctival sac.
- D. Place the drops in the inner canthus and apply pressure.
Correct Answer: B
Rationale: For adults, pulling the ear up and back straightens the ear canal for otic drops. Down/back is for children, others are for ophthalmic drops.
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask client to cough sputum into container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
An adult is receiving gentamicin IV q8h. Which laboratory tests does the nurse expect that the client will have done regularly?
- A. CBC and hemoglobin
- B. BUN and serum creatinine
- C. SGOT and SGPT
- D. Urine and blood cultures
Correct Answer: B
Rationale: BUN and serum creatinine are tests of renal function. Gentamicin is nephrotoxic. All persons receiving gentamicin should have these tests done regularly to assess for toxicity.