Nokea
The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.
- A. Client with iron deficiency anemia takes iron supplements with milk
- B. Client takes levothyroxine early in the morning on an empty stomach
- C. Client taking phenazopyridine for urine infection states that the urine has turned orange
- D. Client taking metronidazole mentions going to a wine-tasting party tonight
- E. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold
Correct Answer: A,D,E
Rationale: Milk reduces iron absorption, metronidazole with alcohol can cause severe reactions, and diphenhydramine can worsen closed-angle glaucoma.
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The nurse is caring for a client diagnosed with active pulmonary tuberculosis. Which elements of transmission-based precautions are required for the nurse when providing routine care? Select all that apply.
- A. Gown
- B. Goggles or face shield
- C. Hand hygiene
- D. N95 particulate respirator
- E. Surgical mask
Correct Answer: C,D
Rationale: Active pulmonary tuberculosis requires airborne precautions, including hand hygiene and an N95 respirator. A surgical mask is insufficient.
A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?
- A. Elbow
- B. Mummy
- C. Jacket
- D. Clove hitch
Correct Answer: A
Rationale: Elbow. The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.
Which of the following musical instruments is best for a teen with asthma?
- A. Guitar
- B. Piano
- C. Drums
- D. Clarinet
Correct Answer: A
Rationale: The guitar does not require breath control, making it suitable for a teen with asthma, unlike wind instruments like the clarinet.
The nurse is observing the movements of a client receiving Thorazine (chlorpromazine). The client continually paces and rocks back and forth when sitting. The nurse recognizes that the client is experiencing:
- A. Oculogyric crisis
- B. Akathisia
- C. Dystonia
- D. Bradykinesia
Correct Answer: B
Rationale: Akathisia is characterized by restlessness, pacing, and rocking, which matches the client's symptoms. Answer A involves fixed upward gaze, Answer C involves muscle spasms, and Answer D involves slowed movements, all of which are incorrect.
The nurse is preparing to administer sumatriptan to a client with a migraine headache. Which of the following findings would require follow-up prior to administering the medication?
- A. BMI of 34 kg/m recorded during today's examination
- B. past medical history of uncontrolled hypertension
- C. takes alprazolam as prescribed for anxiety
- D. BUN of 12 mg/dL (4.28 mmol/L)
Correct Answer: B
Rationale: Sumatriptan is contraindicated in uncontrolled hypertension due to the risk of cardiovascular events.