Nokea
The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?
- A. How to transmit the readings over the phone
- B. Keep a diary of activities and any symptoms experienced
- C. Refrain from exercising while wearing the monitor
- D. The monitor may be removed only when bathing
Correct Answer: B
Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.
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The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly?
- A. Ranitidine 150 mg daily by mouth
- B. Ranitidine 150 mg per os qhs
- C. Ranitidine 150 mg po qd nightly
- D. Ranitidine 150 mg PO at bedtime
Correct Answer: D
Rationale: Ranitidine 150 mg PO at bedtime accurately specifies the dose, route, and timing (qhs = at bedtime). Other options are less precise or redundant (e.g., ‘qd nightly’).
The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?
- A. Urinary output of $60 \mathrm{ml}$ per hour
- B. Respirations of 30 per minute
- C. Absence of the knee-jerk reflex
- D. Blood pressure of $150 / 80$
Correct Answer: C
Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.
The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply.
- A. Add high-protein foods to diet
- B. Consume high-carbohydrate meals
- C. Eat small, frequent meals
- D. Increase intake of fluids with meals
- E. Lie down after eating
Correct Answer: A,C
Rationale: High-protein foods and small, frequent meals slow gastric emptying, preventing dumping syndrome. High-carb meals and fluids with meals speed emptying, and lying down delays digestion, worsening symptoms.
The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?
- A. Answer the bell quickly each time she rings
- B. Say, 'I do not have time to be in your room constantly.'
- C. Say, 'Why are you so upset?'
- D. Say, 'You seem concerned about something.'
Correct Answer: D
Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.
The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?
- A. A 13 month-old unable to walk
- B. A 20 month-old only using 2 and 3 word sentences
- C. A 24 month-old who cries during examination
- D. A 30 month-old only drinking from a sippy cup
Correct Answer: D
Rationale: A 30 month-old only drinking from a sippy cup. A 30 month-old should be able to drink from a cup without a cover.