Nokea
A client before administration of captopril (Capoten).
The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's
- A. apical pulse for 60 seconds.
- B. blood pressure.
- C. urine output.
- D. temperature.
Correct Answer: B
Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication
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The nurse is performing a sterile dressing change. Which action is essential?
- A. Touching the corners of the dressing with clean gloves
- B. Discussing the wound with the client during the dressing change
- C. Irrigating the wound with an antiseptic solution
- D. Wearing sterile gloves during the dressing change
Correct Answer: D
Rationale: Wearing sterile gloves maintains a sterile field, essential for preventing infection during a sterile dressing change.
A nursing assistant reports to the RN that a patient with anemia is complaining of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?
- A. Listen to the patient's breath sounds and report back to me.'
- B. Set up the patient's lunch tray.'
- C. Obtain a diet history from the patient.'
- D. Instruct the patient to balance rest and activity.'
Correct Answer: B
Rationale: standard, unchanging procedure; decrease cardiac workload
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
- A. Remove the unsightly markings with acetone or alcohol.
- B. Cover the radiation site with loose gauze dressing.
- C. Sprinkle baby powder over the radiated area.
- D. Refrain from using soap or lotion on the marked area.
Correct Answer: D
Rationale: Refraining from using soap or lotion preserves radiation site markings, ensuring accurate treatment. Removing markings, covering, or using powder risks disrupting the treatment field.
The school nurse is teaching a group of preschool mothers about poison prevention in the home.
- A. Which statement by a mother indicates that further teaching is necessary?
- B. I should have a bottle of Ipecac for each of my children.'
- C. I should induce vomiting if my child swallows lighter fluid.'
- D. Giving my child water or milk may help dilute the poison.'
- E. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. The other statements are correct: Ipecac is recommended for emergency use, diluting with water or milk can help, and proper storage is essential for prevention.
An elderly client with glaucoma is scheduled for an exploratory laparotomy. Which of the following pre-op medications should be questioned?
- A. Demerol (meperidine)
- B. Atropine (atropine)
- C. Tagamet (cimetadine)
- D. Polycillin (ampicillin)
Correct Answer: B
Rationale: Atropine is contraindicated in glaucoma as it can increase intraocular pressure. Demerol , Tagamet , and Polycillin are generally safe in this context.