Nokea
The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?
- A. atorvastatin
- B. enoxaparin
- C. furosemide
- D. metoprolol
Correct Answer: D
Rationale: Metoprolol (D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (C) treats fluid overload, enoxaparin (B) prevents thrombosis, and atorvastatin (A) manages lipids.
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A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should
- A. Eat foods high in sodium to increase sputum liquefaction
- B. Use oxygen during meals to improve gas exchange
- C. Perform exercise after respiratory therapy to enhance appetite
- D. Cleanse the mouth of dried secretions to reduce risk of infection
Correct Answer: B
Rationale: Use oxygen during meals to improve gas exchange. This supports breathing and energy needs during eating.
A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin to treat angina. Which statement by the client indicates that further teaching is required?
- A. I may experience flushing but will continue to take the medication as prescribed.
- B. I should lie down before taking the medication.
- C. I should not swallow the tablet.
- D. I will wait to call 911 if I don't experience relief after the third tablet.
Correct Answer: D
Rationale: Delaying 911 after three doses (D) is dangerous; clients should call after no relief from the first dose or after three doses (5 minutes apart). Flushing (A), lying down (B), and not swallowing (C) are correct.
The nurse is observing a staff member collecting a sputum specimen from a client with active tuberculosis. The nurse should intervene if the staff member is observed
- A. leaving unused supplies in the client's room after the procedure
- B. putting on clean gloves before putting on a protective gown
- C. leaving a dedicated, disposable stethoscope in the client's room
- D. putting on an N95 respirator mask and face shield before entering the client's room
Correct Answer: A
Rationale: Leaving supplies (A) in a TB room risks contamination. Gloves before gown (B), dedicated stethoscope (C), and N95 with face shield (D) are appropriate.
The nurse is reinforcing skin care guidelines for a client who is receiving external radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will apply an ice pack to the treatment site if my skin begins to burn.
- B. I will rub baby oil on the site after each treatment to prevent dry skin.
- C. I will use extra measures to protect my skin from sun exposure.
- D. I will wash the treatment site with lukewarm water and mild soap.
- E. I will wear soft, loose-fitting clothing.
Correct Answer: C,D,E
Rationale: Sun protection (C), gentle washing (D), and loose clothing (E) are correct for radiation therapy skin care. Ice packs (A) can damage skin, and baby oil (B) may irritate or trap radiation.
The nurse is preparing to administer IV furosemide to a client with chronic kidney disease. The nurse should administer the medication slowly to prevent
- A. oliguria
- B. ototoxicity
- C. bradycardia
- D. hypertension
Correct Answer: B
Rationale: Rapid IV furosemide can cause ototoxicity (B) in CKD patients due to drug accumulation. Oliguria (A) is already present, and furosemide does not typically cause bradycardia (C) or hypertension (D).