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The nurse is caring for an adult for whom phenytoin (Dilantin) has been prescribed. Which is of greatest concern to the nurse?
- A. The client's urine has a pinkish tinge to it.
- B. The client has enlarged gums.
- C. The client's serum Dilantin level is 14 mcg/mL.
- D. The client says, 'I usually go to Happy Hour every Friday.'
Correct Answer: B
Rationale: Gingival hyperplasia is a significant side effect of phenytoin, requiring dental care and possible dose adjustment, more concerning than normal urine discoloration or social drinking.
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A comatose patient who is incontinent.
The nurse should intervene if which of the following actions is noted?
- A. The nurse assistant answers the phone while wearing gloves.
- B. The nursing assistant log rolls the patient to provide back care.
- C. The nursing assistant places an incontinence pad under the patient.
- D. The nursing assistant positions the patient on the left side, head elevated.
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
A 7-year-old daughter weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year.
Which of the following responses by the nurse is BEST?
- A. Your daughter's height and weight are within normal limits.'
- B. Your daughter's height is normal, but she needs to gain some weight.'
- C. Your daughter's height is normal, but she needs to lose some weight.'
- D. Your daughter's weight is normal, but she is shorter than normal.'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates that you will have to discriminate between answers. The topic of the question is unstated. Read answer choice to obtain clues. (1) correct-between ages 6-12 grows about 2 in (5 cm)/year and gains 4.5-6.5 lb (2-3 kg)/year, at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 in (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urinary output of 200 mL/hour.
- D. Blood-tinged urine.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-prostatectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, high urinary output, and blood-tinged urine are normal on day 1.
The nurse is teaching a client with chronic kidney disease about dietary restrictions. Which of the following foods should the nurse advise the client to limit?
- A. Fresh strawberries.
- B. Baked chicken.
- C. Potato chips.
- D. Brown rice.
Correct Answer: C
Rationale: Potato chips are high in sodium and potassium, which must be limited in chronic kidney disease to prevent fluid retention and hyperkalemia. Options A, B, and D are more suitable: strawberries are low-potassium, chicken is protein-rich, and brown rice is acceptable in moderation.
The nurse is caring for a client in the outpatient clinic who is four months pregnant.
- A. Which symptom reported by a four-month pregnant client requires immediate follow-up?
- B. Intermittent nausea in the morning.
- C. A white vaginal discharge.
- D. Breast tenderness bilaterally.
- E. Feeling the need to void more frequently.
Correct Answer: A
Rationale: Intermittent nausea in the second trimester (four months) is abnormal, as morning sickness typically resolves by the end of the first trimester, and may indicate complications like hyperemesis gravidarum or other issues requiring evaluation. Vaginal discharge, breast tenderness, and frequent urination are normal pregnancy symptoms.