Nokea
The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.
- A. Falls asleep when the nurse is talking
- B. Frequently scratches from pruritus
- C. Has third emesis since taking medication
- D. Monitor shows occasional premature ventricular contractions
- E. Pulse oximetry reading is 92%
Correct Answer: A,C,D
Rationale: Falling asleep (A), vomiting (C), and premature ventricular contractions (D) indicate possible methadone overdose or toxicity, requiring extended monitoring. Pruritus (B) is a common side effect, and 92% oxygen saturation (E) is not critical.
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A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client?
- A. A diet rich in protein and vitamin D will help with absorption.
- B. If the tablet is too large to swallow, crush and take it in applesauce or pudding.
- C. Potassium tablets should be taken on an empty stomach.
- D. Take it with plenty of water and sit upright for a period of time afterward.
Correct Answer: D
Rationale: Potassium chloride tablets should be taken with water and the client should remain upright to prevent esophageal irritation or ulceration (D). Protein and vitamin D (A) do not enhance absorption, crushing tablets (B) can cause irritation, and taking on an empty stomach (C) is unnecessary.
Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
The nurse is talking with a client who has a new prescription for misoprostol to prevent gastric ulcers. Which of the following statements by the client would require follow-up?
- A. I will take this medication with meals and at bedtime.
- B. I plan to use a reliable form of birth control while taking this medication.
- C. I can take this medication with an antacid to prevent an upset stomach.
- D. I should notify my health care provider if I develop black, tarry stools while taking this medication.
Correct Answer: C
Rationale: Taking misoprostol with antacids (C) reduces its efficacy and requires follow-up. Taking with meals (A), using contraception (B), and reporting black stools (D) are correct.
The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?
- A. He has been taking long naps for a week.'
- B. He has had an ear infection for the past 2 days.'
- C. He has been eating more red meat lately.'
- D. He seems to be going to the bathroom more frequently.'
Correct Answer: B
Rationale: He has had an ear infection for the past 2 days.' Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.
The nurse is caring for a client who is recovering from a cerebrovascular accident and is partially paralyzed on the right side. How should the nurse position the chair when getting the client out of bed?
- A. On the right side of the bed facing the foot of the bed
- B. On the right side of the bed facing the head of the bed
- C. On the left side of the bed facing the foot of the bed
- D. On the left side of the bed facing the head of the bed
Correct Answer: C
Rationale: Placing the chair on the left (unaffected) side facing the foot allows the client to pivot using their stronger side, facilitating safe transfer. Right-side placement or incorrect orientation hinders mobility.