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The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:
- A. Discard the solution.
- B. Obtain a bag of normal saline.
- C. Cover both the solution bag and the IV tubing with foil.
- D. Do nothing because the solution is expected to be light brown in color.
Correct Answer: D
Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.
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The nurse in an ambulatory care center is reinforcing teaching to a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride sustained release. What statement by the client indicates a need for further teaching?
- A. If I have a sudden change in my mood, I should call my physician immediately.
- B. If I have trouble swallowing the tablet, I can cut it in half.
- C. If I miss a dose, I should not double the next dose to catch up.
- D. It may take several weeks before I get better.
Correct Answer: B
Rationale: Bupropion sustained-release tablets must not be cut, as this disrupts the controlled-release mechanism, risking side effects. Other statements are correct: mood changes require reporting, missed doses shouldn't be doubled, and therapeutic effects take weeks.
The nurse is caring for a client who will not use the train for transportation due to the fear of being trapped and unable to escape. The nurse should recognize that the client is likely experiencing
- A. generalized anxiety disorder
- B. social anxiety disorder
- C. agoraphobia
- D. acrophobia
Correct Answer: C
Rationale: Fear of being trapped in situations (e.g., trains) with no escape is characteristic of agoraphobia. Generalized anxiety involves broad worries, social anxiety focuses on social scrutiny, and acrophobia is fear of heights.
The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel?
- A. Check the blood glucose before meals and report it to the nurse
- B. Instruct the client to cut toenails straight across and file any sharp edges
- C. Monitor the client for signs and symptoms of hypoglycemia
- D. Update the care plan to include client's preference for a nighttime diabetic snack
Correct Answer: A
Rationale: Checking blood glucose and reporting results is within UAP scope if trained. Teaching, monitoring for hypoglycemia, and updating care plans require nursing judgment and are outside UAP scope.
Written instructions to pregnant women include instructions to perform Kegel exercises. One of the women asks the nurse why these exercises are important. The nurse should reply that the purpose of these exercises is to:
- A. increase circulation to the uterus.
- B. strengthen the muscles of the pelvic floor.
- C. prepare the breasts for nursing.
- D. condition the pregnant woman for the 'work' of childbirth.
Correct Answer: B
Rationale: Kegel exercises strengthen pelvic floor muscles, supporting bladder control and aiding postpartum recovery, directly addressing their purpose.
The home care nurse is observing the client's spouse performing a colostomy irrigation. Which action needs correction?
- A. The spouse holds the irrigating solution about 18 inches above the stoma.
- B. The client is sitting on the toilet seat for the irrigation.
- C. The spouse is using 1000 mL of irrigating solution.
- D. The spouse uses petroleum jelly to lubricate the tip of the catheter.
Correct Answer: D
Rationale: Petroleum jelly is not suitable for lubricating colostomy irrigation catheters, as it may degrade materials or harbor bacteria; water-soluble lubricant is preferred. The height, volume, and position are appropriate.