Nokea
The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?
- A. The client's nutritional status.
- B. The client's circulatory status.
- C. The client's mobility status.
- D. The client's orientation status.
Correct Answer: C
Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.
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A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects?
- A. Gingival hyperplasia.
- B. Weight gain.
- C. Insomnia.
- D. Dry skin.
Correct Answer: A
Rationale: Phenytoin commonly causes gingival hyperplasia, which should be reported to manage oral health and adjust treatment if needed.
A client with a history of type 2 diabetes is prescribed exenatide (Byetta). The nurse should instruct the client to:
- A. Take the medication before meals.
- B. Monitor for signs of hypoglycemia.
- C. Take the medication at bedtime.
- D. Stop the medication if weight loss occurs.
Correct Answer: A, B
Rationale: Exenatide is taken before meals to control postprandial glucose, and hypoglycemia is a risk.
Your client is experiencing general malaise. Which stage of infection is this client in?
- A. The incubation stage
- B. The illness stage
- C. The prodromal stage
- D. The convalescence stage
Correct Answer: B
Rationale: General malaise is characteristic of the illness stage, where symptoms of the infection are most prominent.
A client with a history of chronic kidney disease is admitted with hyperkalemia. The nurse should prioritize which of the following interventions?
- A. Administer insulin and glucose.
- B. Restrict potassium-rich foods.
- C. Administer a loop diuretic.
- D. Monitor for dysrhythmias.
Correct Answer: D
Rationale: Monitoring for dysrhythmias is the priority, as hyperkalemia can cause life-threatening cardiac arrhythmias.
A client with a history of cirrhosis is admitted with esophageal varices. The nurse should monitor the client for which of the following complications?
- A. Hematemesis.
- B. Hypotension.
- C. Fever.
- D. Constipation.
Correct Answer: A, B
Rationale: Esophageal varices can rupture, causing hematemesis and hypotension.