Nokea
The nurse is caring for a client with a history of gastric ulcer who is prescribed sucralfate (Carafate). The nurse should instruct the client to take the medication:
- A. With meals to enhance absorption.
- B. On an empty stomach.
- C. At bedtime only.
- D. With an antacid.
Correct Answer: B
Rationale: Sucralfate should be taken on an empty stomach to coat the gastric mucosa effectively, promoting ulcer healing.
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A client with rheumatoid arthritis tells the nurse that she feels 'quite alone' in adjusting to changes in her lifestyle. Which of the following nursing actions is most appropriate in response to this statement?
- A. Refer the client and her husband for counseling to decrease her sense of isolation.
- B. Suggest the client develop a hobby to occupy her time.
- C. Tell the client about her community's arthritis support group.
- D. Suggest that the client discuss her feelings with her minister.
Correct Answer: C
Rationale: A community arthritis support group provides peer support, reducing feelings of isolation and addressing specific needs.
A client with a history of heart failure is admitted with jugular vein distension. The nurse should include which of the following in the plan of care?
- A. Administer furosemide as prescribed.
- B. Position the client in Fowler's position.
- C. Restrict sodium intake.
- D. Encourage ambulation.
Correct Answer: A, B, C
Rationale: Furosemide, Fowler's position, and sodium restriction reduce fluid overload in heart failure.
A diabetic client who takes insulin is being seen by the nurse for a low blood glucose level. Which of the following would be the best choices to begin to raise the blood glucose level? Select all that apply.
- A. One-half cup of orange juice.
- B. One cup of milk.
- C. One ounce of tuna.
- D. One tablespoon of peanut butter.
- E. One piece of bread.
- F. One-half cup of regular soda.
Correct Answer: A, B, E, F
Rationale: Orange juice, milk, bread, and regular soda contain fast-acting carbohydrates to raise blood glucose quickly.
You measure your 5 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 100 beats per minute • Blood pressure: 85/55. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: A
Rationale: For a 5-year-old, normal ranges are approximately: respiratory rate 20-25 breaths/min, pulse 70-115 beats/min, blood pressure ~90-110/55-65 mmHg. The respiratory rate (32) is slightly high, while the pulse and blood pressure are within normal limits.
Which of the following interventions is recommended protocol for all clients who are at risk for pressure sore development?
- A. Identify clients at risk upon admission to the health care facility.
- B. Place at-risk clients on an every-2-hour turning schedule.
- C. Automatically place clients in specialty beds.
- D. Provide at-risk clients with a high-protein, high-carbohydrate diet.
Correct Answer: B
Rationale: Regular repositioning every 2 hours prevents prolonged pressure on skin, reducing the risk of pressure sores in at-risk clients.