Nokea
The nurse is caring for a client with a history of gastroesophageal reflux disease (GERD).
- A. Which instruction is most appropriate for a client with GERD?
- B. Eat large meals to reduce acid production.
- C. Lie down immediately after eating.
- D. Elevate the head of the bed during sleep.
- E. Avoid drinking water with meals.
Correct Answer: C
Rationale: Elevating the head of the bed during sleep prevents acid reflux by using gravity to keep stomach contents down. Large meals and lying down post-meal worsen reflux, and water is neutral.
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Which of the following nursing approaches would be MOST appropriate to use while administering an oral medication to a four-month-old?
- A. Place the medication in 45 cc of formula.
- B. Place the medication in an empty nipple and allow the infant to suck.
- C. Place the medication in a full bottle of formula.
- D. Administer the medication using a plastic syringe, with the infant in the reclining position.
Correct Answer: B
Rationale: is a convenient method for administering medications to an infant
The nurse is caring for a client with a history of seizures. The client begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take FIRST?
- A. Restrain the client to prevent injury.
- B. Place a tongue depressor in the client's mouth.
- C. Turn the client to the side.
- D. Administer lorazepam (Ativan) IV.
Correct Answer: C
Rationale: turning the client to the side helps maintain a patent airway and prevents aspiration during a seizure
The nurse is caring for a 34-year-old man admitted with low back pain. The history indicates that the patient has hemophilia A. The nurse should question which of the following orders?
- A. Ketorolac tromethamine (Toradol).
- B. Codeine phosphate (Paveral).
- C. Oxycodone terephthalate (Percodan).
- D. Hydromorphone hydrochloride (Dilaudid).
Correct Answer: C
Rationale: contraindicated for persons with bleeding disorders, contains aspirin
The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be most important for the nurse to make which of the following statements?
- A. Take this medication with food.
- B. Take this medication one hour before meals.
- C. Take this medication one hour after meals.
- D. Take this medication with orange juice.
Correct Answer: A
Rationale: reduces GI upset
An elderly man diagnosed with chronic schizophrenia is being followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and has recently developed symptoms of tardive dyskinesia.
The nurse's documentation on this client should include
- A. assessment of ADL (self-care) ability.
- B. Mini-Mental Status Examination (MMSE).
- C. Abnormal Involuntary Movement Scale (AIMS).
- D. Modified Overt Aggression Scale (MOAS).
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) assessment of client's abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill (2) measures cognitive function (3) correct-is most widely accepted examination to Test for the presence of tardive dyskinesia (4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population