Nokea
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
- A. Cover the neonate's eyes.
- B. Apply lotion to the skin.
- C. Keep the neonate swaddled.
- D. Monitor urine output daily.
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.
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When a daily dose of fluoxetine hydrochloride is prescribed for a client, the nurse provides instructions regarding its administration. Which statement by the client indicates an understanding regarding the administration of the medication?
- A. I should take the medication with food only.
- B. It is best to take the medication in the morning.
- C. I should take the medication at bedtime with a snack.
- D. I should take the medication at noontime with an antacid.
Correct Answer: B
Rationale: A daily dose of fluoxetine hydrochloride, a selective serotonin reuptake inhibitor (SSRI), should be taken in the morning. If the medication is prescribed more than once daily, then the client is instructed to take the last dose of the day before 4:00 pm to avoid insomnia. It does not have to be taken with food. Antacids are avoided with its administration because the antacid will affect absorption.
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
- A. Administer the dose as ordered.
- B. Hold the dose and notify the physician.
- C. Administer half the prescribed dose.
- D. Administer vitamin K as an antidote.
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
- A. Halloween is getting close, isn't it.'
- B. Do you have a black cat?'
- C. What's the connection between cats, hats, and time?'
- D. Time certainly does go faster these days.'
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.
The client is receiving propantheline bromide (Pro-Banthine) to treat cholecystitis. The nurse should evaluate the client's response to the medication by observing for which of the following adverse effects?
- A. Urine retention.
- B. Diarrhea.
- C. Hypertension.
- D. Diaphoresis.
Correct Answer: A
Rationale: Propantheline, an anticholinergic, can cause urine retention due to reduced bladder contractility. Diarrhea, hypertension, and diaphoresis are not typical side effects.
The nurse is teaching a client with a new diagnosis of hypertension about dietary modifications. Which of the following recommendations is most effective?
- A. Increase calcium intake.
- B. Reduce saturated fat intake.
- C. Limit carbohydrate intake.
- D. Avoid potassium-rich foods.
Correct Answer: B
Rationale: Reducing saturated fat intake lowers cholesterol and blood pressure, benefiting hypertension management.