Nokea
The nurse aus.Concurrent with the above question, the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?
- A. Administer an inhaled bronchodilator
- B. Check marked insertion depth of the tube
- C. Request a prescription for a diuretic
- D. Start the client on incentive spirometry
Correct Answer: C
Rationale: Crackles and diminished breath sounds in the lung bases postpartum suggest fluid overload or pulmonary edema, possibly due to prolonged labor or excessive IV fluids. Requesting a diuretic is appropriate to reduce fluid overload. Bronchodilators are for bronchospasm, checking tube depth is irrelevant without an endotracheal tube, and incentive spirometry is less urgent.
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A client with iron deficiency anemia is started on ferrous sulfate tablets. The nurse has instructed the client on the appropriate way to take her medication. Which of the following statements indicates that the client understands the nurse's teaching?
- A. I can take my iron tablets with a glass of milk.'
- B. I need to take my iron tablets daily before breakfast.'
- C. Taking my iron tablets before I go to bed will cut down on stomach upset.'
- D. Taking my iron tablets with a glass of orange juice will help me absorb more of the medicine.'
Correct Answer: D
Rationale: Vitamin C (in orange juice) enhances iron absorption. Milk reduces absorption, and timing (breakfast or bedtime) is less critical.
A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to
- A. add dietary fiber
- B. reduce ammonia levels
- C. stimulate peristalsis
- D. control portal hypertension
Correct Answer: B
Rationale: Lactulose blocks the absorption of ammonia from the GI tract and secondarily stimulates bowel elimination.
The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?
- A. Administer morphine to the client.
- B. Verify when the client had the last flatus or bowel movement.
- C. Administer oxybutynin to the client.
- D. Verify the amount and characteristics of the client's urine output.
Correct Answer: D
Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.
The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?
- A. I can leave right after the shot as I didn't have a reaction last time.'
- B. I will be back in a week for my next allergy shot.'
- C. I will let the doctor know if I get any itchy hives tonight.'
- D. It is okay if I have some redness at the injection site tonight.'
Correct Answer: A
Rationale: Leaving immediately after an allergy shot is unsafe due to the risk of delayed anaphylaxis, requiring a 20–30 minute observation period. Weekly shots , reporting hives , and mild redness are appropriate.
It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP? Select all that apply.
- A. Elevate the right leg on two pillows.'
- B. Measure client for compression stockings.'
- C. Please let me know what the urine looks like.'
- D. Tell me what the client eats at lunch.'
- E. Verify wrist restraints are on correctly.'
Correct Answer: A,C,D
Rationale: Appropriate UAP tasks include elevating a leg , observing urine appearance , and reporting food intake . Measuring for stockings and verifying restraints require nursing judgment.