Nokea
The client is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?
- A. Rest in bed after taking the medication for at least 30 minutes
- B. Avoid rapid movements after taking the medication
- C. Take the medication with water only
- D. Allow at least 1 hour between taking the medicine and taking other medications
Correct Answer: B
Rationale: When a client is prescribed alendronate (Fosamax), instructing them to avoid rapid movements after taking the medication is crucial to prevent esophageal irritation. Resting in bed after taking the medication for at least 30 minutes (choice A) is not necessary and can increase the risk of side effects. While taking the medication with water only (choice C) is generally recommended, the key instruction to prevent esophageal irritation is to avoid rapid movements. Allowing at least 1 hour between taking the medicine and other medications (choice D) is not specifically related to the administration of alendronate and is not the primary concern when giving instructions to the client.
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A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers on the left foot
Correct Answer: C
Rationale: The correct answer is the client with laryngeal cancer who had a laryngectomy. This client is at risk for airway obstruction due to the surgical procedure, making it a priority visit. Clients with AIDS (choice A), a fractured femur (choice B), and diabetic ulcers (choice D) do not have immediate life-threatening conditions that require urgent attention compared to a client with a recent laryngectomy.
In the emergency room, a nurse is responsible for triaging four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
- A. A 10-year-old with lacerations on the face
- B. A 15-year-old with sternal bruises
- C. A 34-year-old with a fractured femur
- D. A 50-year-old with a dislocated elbow
Correct Answer: B
Rationale: The 15-year-old with sternal bruises should receive priority in care as this client might be experiencing airway and oxygenation problems. Airway issues take precedence in triage. The 10-year-old with lacerations on the face, although looking bad, is not in immediate distress. The 34-year-old with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The 50-year-old with a dislocated elbow can also be seen later as dislocated elbows are not life-threatening compared to potential airway compromise.
The nurse is making initial rounds on a client with a C5 fracture and crutch field tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct Answer: B
Rationale: A torque wrench is essential equipment to keep at the bedside for a client with a C5 fracture and crutch field tongs. This tool is used to tighten and loosen the screws of the crutch field tongs, allowing the nurse to adjust the pressure on the screws for proper support and alignment. A pair of forceps (choice A), wire cutters (choice C), and a screwdriver (choice D) are not required for managing crutch field tongs and, therefore, are incorrect choices in this scenario.
When assessing a client in crisis, what should the nurse prioritize?
- A. Allowing the client to work through independent problem-solving.
- B. Completing an in-depth evaluation of stressors and responses to the situation.
- C. Focusing on immediate stress reduction.
- D. Recommending ongoing therapy.
Correct Answer: C
Rationale: When a client is in crisis, the nurse's priority is to focus on immediate stress reduction. Crisis intervention aims to stabilize the client in the present moment by addressing the most pressing issues. Allowing the client to work through independent problem-solving (Choice A) may not be appropriate during a crisis as they might need immediate support. Completing an in-depth evaluation of stressors (Choice B) is important but not the immediate priority during a crisis. Recommending ongoing therapy (Choice D) may be considered later, but the immediate focus should be on reducing the client's stress and stabilizing the situation.
A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:
- A. "The amount of alcohol that is safe during pregnancy is unknown."?
- B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
- C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
- D. "You can have a drink to help you relax and get to sleep at night."?
Correct Answer: A
Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? This response is appropriate because there is no known safe amount of alcohol consumption during pregnancy. Consuming any amount of alcohol during pregnancy can pose risks to the developing fetus, leading to conditions like fetal alcohol syndrome, which is a combination of mental and physical abnormalities in infants. Choices B, C, and D are incorrect. Choice B suggests that consuming one or two drinks a day is safe during pregnancy, which is not supported by current medical guidelines. Choice C incorrectly states that only drinking three or more drinks on any given occasion is harmful, when in reality, any amount of alcohol can be harmful to the fetus. Choice D is inappropriate as it suggests that having a drink to relax and sleep is acceptable during pregnancy, which is not the case.