Nokea
The nurse is caring for a client who has gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for developing
- A. jaw necrosis
- B. vision changes
- C. gait disturbance
- D. Clostridoides difficile infection
Correct Answer: D
Rationale: Long-term omeprazole increases risk of C. difficile due to altered gut flora. Jaw necrosis , vision changes , and gait disturbance are not associated.
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Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
- A. Venturi mask
- B. Partial rebreather mask
- C. Non-rebreather mask
- D. Simple face mask
Correct Answer: C
Rationale: Non-rebreather mask. The non-rebreather mask has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.
The nurse is reviewing new orders for a client with chronic kidney disease. The nurse should clarify the order for
- A. dietary sodium restriction
- B. magnesium hydroxide
- C. fluid restriction
- D. furosemide
Correct Answer: B
Rationale: Magnesium hydroxide risks toxicity in CKD due to impaired excretion. Sodium restriction , fluid restriction , and furosemide are appropriate.
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest
- A. during the night shift when staffing is limited
- B. when the client's mood improves with an increase in energy level
- C. at the time of the client's greatest despair
- D. after a visit from the client's estranged partner
Correct Answer: B
Rationale: Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.
An adult is almost ready for discharge. She has a complicated care regimen to follow. When conducting client teaching, the nurse notes that the client cannot recall basic information that was discussed the day before. The client also appears distracted. When asked if she is feeling comfortable about leaving the hospital, she states, 'There's just too much to learn. I know I'm going to get home and mess something up.' The nurse realizes that the client may be experiencing:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. panic anxiety.
Correct Answer: B
Rationale: Difficulty recalling information and expressed worry about managing care suggest moderate anxiety, impairing learning but not reaching panic.
The nurse is discussing hypertension with a group of people. Which person is at greatest risk for hypertension?
- A. A 63-year-old overweight Caucasian female office worker who smokes and whose parents both had high blood pressure.
- B. A 52-year-old African-American female of normal weight whose parents have diabetes and who is an avid swimmer.
- C. A 48-year-old Hispanic-American smoker whose father had high blood pressure.
- D. A 45-year-old Native American who leads a sedentary life and smokes.
Correct Answer: A
Rationale: Age, obesity, smoking, and family history of hypertension confer the highest risk, as seen in the 63-year-old Caucasian female.