Nokea
The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
- A. Skin irritation
- B. Drug tolerance
- C. Severe headaches
- D. Postural hypotension
Correct Answer: B
Rationale: Drug tolerance. Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
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The nurse is reinforcing information on dietary management to a group of clients with newly diagnosed type 2 diabetes. Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning?
- A. Baked tilapia with tomato salsa, steamed white rice
- B. Black bean chili with brown rice, mixed greens salad
- C. Grilled chicken breast with baked French fries
- D. Hamburger on a whole wheat bun with lettuce and tomato
Correct Answer: B
Rationale: Baked bean chili with brown rice and salad provides fiber, lean protein, and vegetables, balancing blood sugar. Fries and hamburger buns are higher in simple carbs, less ideal for diabetes control.
The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.
- A. I exhale for 2 seconds through pursed lips
- B. I exhale for 4 seconds through pursed lips
- C. I inhale for 2 seconds through my mouth
- D. I inhale for 2 seconds through my nose, keeping my mouth closed
- E. I inhale for 4 seconds through my nose, keeping my mouth closed
Correct Answer: B,D
Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.
The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
- A. Reporting joint stiffness in the morning
- B. Taking the medication 1 hour before or 2 hours after meals
- C. Using alcohol in moderation unless driving
- D. Continuing to take aspirin for short term relief
Correct Answer: B
Rationale: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.
The nurse is talking with a client recently diagnosed with HIV infection about home and lifestyle alterations. Which of the following statements indicate that the client correctly understands the teaching? Select all that apply.
- A. I should avoid eating raw or undercooked meats and eggs to prevent infections
- B. I need to make sure my family members understand not to borrow my shaving razors
- C. I do not need to use barrier methods of protection if my sexual partner is also HIV positive
- D. I have started to use latex-free condoms during sexual intercourse because I have a latex allergy
Correct Answer: A,B,D
Rationale: Avoiding raw foods, not sharing razors, and using latex-free condoms reduce infection and transmission risks. Barrier methods are still needed with HIV-positive partners to prevent superinfection.
The nurse is evaluating the effectiveness of the medication regimen for a client with chronic kidney disease who is receiving sodium polystyrene sulfonate. It would indicate that the medication regimen has been effective if the client’s most recent laboratory test results indicate
- A. an increase in the serum calcium level
- B. an increase in the serum creatinine level
- C. a decrease in the serum potassium level
- D. a decrease in the serum phosphate level
Correct Answer: C
Rationale: Sodium polystyrene sulfonate treats hyperkalemia in chronic kidney disease by exchanging sodium for potassium in the gut, so a decreased potassium level indicates effectiveness. Calcium levels are not directly affected, and rising creatinine indicates worsening kidney function.