Nokea
The most important long-term goal for a client with hypertension would be to:
- A. Learn how to avoid stress.
- B. Explore a job change or early retirement.
- C. Make a commitment to long-term therapy.
- D. Lose weight.
Correct Answer: C
Rationale: Committing to long-term therapy (e.g., medication, lifestyle changes) is critical for sustained blood pressure control and prevention of complications.
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The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
- A. Assess the oral cavity each time mouth care is given and record observations.
- B. Use a soft toothbrush to brush the client's teeth after each meal.
- C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
- D. Rinse the client's mouth with mouthwash several times a day.
Correct Answer: B
Rationale: Using a soft toothbrush after meals is an effective and safe method for providing oral hygiene, promoting cleanliness without causing trauma.
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
- A. Taking vital signs every 2 hours.
- B. Measuring urine output hourly.
- C. Assessing arterial blood gas values every other day.
- D. Checking blood glucose levels.
Correct Answer: B
Rationale: Diabetes insipidus, often caused by head injury, leads to excessive dilute urine output. Hourly urine output measurement is the most effective way to detect this condition early. Vital signs, blood gases, and glucose levels are less specific for this diagnosis.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
A client with pancreatic cancer is receiving morphine via a subcutaneous pump. The client is developing drug tolerance. The nurse understands that the client is:
- A. Tolerating the medication well.
- B. Showing addiction to morphine.
- C. Requiring an increased dose.
- D. Experiencing physical dependence.
Correct Answer: C
Rationale: Drug tolerance means the client requires an increased dose to achieve the same pain relief, as the body has adapted to the current dose of morphine.
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum creatinine.
- D. Serum calcium.
Correct Answer: C
Rationale: Aminoglycosides are nephrotoxic; monitoring serum creatinine assesses kidney function. Sodium, potassium, and calcium are not primarily affected by aminoglycosides.