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The nurse is caring for a client with a history of peptic ulcer disease who is receiving ranitidine (Zantac) 150 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Mild epigastric discomfort.
- B. Occasional heartburn.
- C. Black, tarry stools.
- D. Nausea after meals.
Correct Answer: C
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious complication in peptic ulcer disease. Options A, B, and D are less urgent.
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A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline, 25 mg/hour. Which one of the following findings by the nurse would require immediate intervention?
- A. Decreased blood pressure and respirations
- B. Flushing and headache
- C. Restlessness and palpitations
- D. Increased heart rate and blood pressure
Correct Answer: C
Rationale: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations.
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
- A. Food
- B. Warmth
- C. Security
- D. Comfort
Correct Answer: C
Rationale: Security. Providing consistent, loving care fosters trust, a key developmental need for infants per Erikson's theory.
An eight-month-old infant.
The nurse should look for which of the following in assessing pain in an eight-month-old infant?
- A. Decreased pulse rate.
- B. Increased fluid intake.
- C. Decreased respiratory rate.
- D. Rubbing a body part and crying.
Correct Answer: D
Rationale: Strategy: Think about each assessment. (1) pulse rate would increase (2) nonspecific regarding pain (3) does not reflect pain (4) correct-since an infant cannot talk, nurse needs to be aware of nonverbal signs of pain, such as rubbing the ear because of an earache
The nurse is teaching a client with a new diagnosis of Parkinson’s disease about levodopa-carbidopa (Sinemet). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should avoid high-protein meals with this medication.
- C. I should report any muscle twitching to my doctor.
- D. I should expect my urine to turn dark.
Correct Answer: D
Rationale: Dark urine is not an expected side effect of levodopa-carbidopa; it may indicate another issue, such as hematuria, requiring investigation. Options A, B, and C are correct: taking on an empty stomach improves absorption, high-protein meals interfere with efficacy, and muscle twitching may indicate toxicity.
The nurse is teaching a client with a new diagnosis of ulcerative colitis about mesalamine (Asacol). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any fever or sore throat
- C. Stop the medication if symptoms improve
- D. Avoid taking with meals
Correct Answer: B
Rationale: Fever or sore throat may indicate bone marrow suppression, a serious mesalamine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks relapse, and it can be taken with meals.