Nokea
The nurse is caring for a client with a history of venous insufficiency who is prescribed horse chestnut extract. The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Bleeding.
- C. Headache.
- D. Fatigue.
Correct Answer: B
Rationale: Horse chestnut extract may increase bleeding risk, so bleeding should be reported immediately.
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The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
- A. Place bedside articles on the left side.
- B. Approach the client from the right side.
- C. Teach the client to scan the environment.
- D. Move the commode and chair to the left side.
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
The nurse is teaching a client with a new diagnosis of asthma about the use of a spacer with a metered-dose inhaler. Which of the following instructions is most important?
- A. Shake the inhaler before attaching it to the spacer.
- B. Inhale quickly to maximize drug delivery.
- C. Clean the spacer with soap and water weekly.
- D. Use the spacer only during an asthma attack.
Correct Answer: C
Rationale: Cleaning the spacer weekly prevents bacterial buildup, ensuring safe and effective medication delivery.
The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure?
- A. Breath sounds
- B. Capillary refill
- C. Respiratory rate
- D. Oxygen saturation level
Correct Answer: A
Rationale: After suctioning a client either with or without an artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions. The other assessment items are not as precise as breath sounds for this purpose.
Ergonovine maleate (Ergotrate) 200 mcg I.M. has been ordered. The ampule label reads 0.2 mg/mL. The nurse should administer how many milliliters?
- A. 1 mL
- B. 2 mL
- C. 0.5 mL
- D. 1.5 mL
Correct Answer: C
Rationale: First, convert micrograms to milligrams: 200 mcg = 0.2 mg. Then: 0.2 mg / X mL = 0.2 mg / 1 mL, so X = 1 mL.
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
- A. Nightingale agitation
- B. Extrapyramidal side effects
- C. Vomiting
- D. Anticholinergic side effects
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.