Nokea
The nurse is caring for a client with oral candidiasis who has a new prescription for nystatin oral suspension. Which of the following actions should the nurse take? Select all that apply.
- A. Tell the client to avoid eating or drinking for at least 30 minutes after taking nystatin.
- B. Monitor the client's oral mucous membranes for redness, swelling, and irritation.
- C. Remind the client to discontinue the nystatin once the symptoms subside.
- D. Shake the bottle of nystatin thoroughly before measuring the dose.
- E. Instruct the client to swish the nystatin around the mouth.
Correct Answer: A,B,D,E
Rationale: For nystatin oral suspension: avoid eating/drinking for 30 minutes to ensure contact time; monitor oral membranes for treatment response; shake the bottle for proper dosing; and swish in the mouth for efficacy. Discontinuing early risks recurrence.
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While sitting at the nurse's station, the nurse observes that a client uses a tissue to pick up magazines and change channels on the television. There has been no such behavior in the past. The nurse should:
- A. Talk with the client about the behavior.
- B. Provide the client with a pair of nonsterile gloves.
- C. Take the tissues away from the client.
- D. Recognize the behavior as a means of getting attention.
Correct Answer: A
Rationale: Talking with the client assesses potential obsessive-compulsive behavior or anxiety. Gloves or removing tissues may escalate distress. Attention-seeking is an assumption without evidence.
A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies
- A. destroy organisms causing disease
- B. maintain fluid balance
- C. boost the immune system
- D. increase bodily energy
Correct Answer: C
Rationale: boost the immune system. The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body's own defenses.
The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?
- A. I will avoid naps later in the day.'
- B. I will keep the bedroom temperature cool.'
- C. I will read in bed before trying to go to sleep.'
- D. I will try to go to bed and wake up at the same time each day.'
Correct Answer: C
Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.
The nurse is caring for a client who has a prescription for albuterol 5 mg via nebulizer every 4 hours. The nurse has albuterol 2.5 mg/3 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
Correct Answer: 6 mL/dose
Rationale: Albuterol 5 mg is needed, with 2.5 mg/3 mL available. Thus, 5 mg ÷ 2.5 mg × 3 mL = 6 mL per dose.
The nurse is collecting data on a client who has arrived at the clinic for pregnancy confirmation and prenatal evaluation. Which of the following findings indicate diagnostic evidence (positive signs) of pregnancy? Select all that apply.
- A. Cervical softening upon examination
- B. Fetal heart tones detected by Doppler device
- C. Positive serum human chorionic gonadotropin test
- D. Report of fetal movement felt by client
- E. Visualization of fetus via ultrasound
Correct Answer: B,E
Rationale: Positive signs of pregnancy are objective, provider-verified findings: fetal heart tones by Doppler and ultrasound visualization . Cervical softening and hCG test are probable signs, and fetal movement is subjective.