Nokea
The nurse is caring for a client with a history of peptic ulcer disease who is experiencing hematemesis. Which of the following interventions is the highest priority?
- A. Administer an antacid.
- B. Insert a nasogastric tube.
- C. Prepare for endoscopy.
- D. Administer a proton pump inhibitor.
Correct Answer: B
Rationale: Inserting a nasogastric tube is the priority to assess and manage active bleeding in hematemesis.
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Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?
- A. Avoid shaving with straight-edge razors.
- B. Clean the skin daily with antibacterial soap.
- C. Apply moisturizing lotion before and after each treatment.
- D. Keep the radiated area covered with a sterile gauze dressing.
Correct Answer: A
Rationale: Avoiding straight-edge razors prevents skin irritation in the radiated area, which is sensitive.
A client who had transurethral resection of the prostate complains of dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had $200 \mathrm{~mL}$ of urine output in the last 8 hours with a $1,000 \mathrm{~mL}$ intake. Which of the following interventions is a priority for the nurse at this time?
- A. Apply a condom catheter
- B. Assess for bladder distention
- C. Obtain a urine specimen for culture
- D. Teach the client Kegel exercises
Correct Answer: B
Rationale: Low urine output and dribbling post-TURP suggest possible bladder distention, which requires immediate assessment to prevent complications. Other interventions may follow based on findings.
When giving a change of shift report, which of the following statements by the nurse is not appropriate?
- A. Randi Smith is a 38-year-old female client of Dr. Born with cholecystitis and cholelithiasis.'
- B. Mrs. Jones' pain is best relieved in the left lateral Sims position.'
- C. Mr. Levi is just contrary today and nothing is going to please him.'
- D. Mr. Emmert was able to walk around the unit twice today with no complaint of dizziness.'
Correct Answer: C
Rationale: Subjective statements like 'contrary' are inappropriate in a professional report, as they lack objectivity and clinical relevance.
The nurse has administered a dose of diazepam to the client. Which most important action should the nurse take before leaving the client's room?
- A. Draw the shades closed.
- B. Provide the client access to a bedpan.
- C. Turn the volume on the television down.
- D. Instruct the client not to get out of bed without assistance.
Correct Answer: D
Rationale: Diazepam is a benzodiazepine and has sedative/hypnotic effects with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse raises a side rail on the bed and instructs the client not to get out of bed without assistance. Note that agency policy regarding the use of side rails is always followed. Although the remaining options may be helpful measures that provide a comfortable, restful environment, instructing the client to ask for assistance when getting out of bed provides for the client's safety needs.
The nurse should give which medication instructions to the client prescribed quinapril hydrochloride?
- A. Take the medication with food only.
- B. Expect a therapeutic effect immediately.
- C. Discontinue the medication if nausea occurs.
- D. Rise slowly from a lying to a sitting position.
Correct Answer: D
Rationale: Quinapril hydrochloride is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. A full therapeutic effect may be noted in 1 to 2 weeks. If nausea occurs, the client should be instructed to take a noncola carbonated beverage and salted crackers or dry toast.