Nokea
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling her legs
- C. Have the client breathe deeply
- D. Provide the client additional fluids
Correct Answer: B
Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.
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The nurse is caring for a client with epilepsy who is to receive Dilantin 100 mg IV push. The client has an IV of D51/2NS infusing at 100 mL/hr. When administering the Dilantin, the nurse should first:
- A. Obtain an ambu bag and put it at bedside
- B. Insert a 16 g IV catheter
- C. Flush the IV line with normal saline
- D. Premedicate with phenergan IV push
Correct Answer: C
Rationale: Dilantin is incompatible with dextrose solutions (D51/2NS), causing precipitation. Flushing with normal saline ensures compatibility and prevents complications.
The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?
- A. Encourage the client to express her feelings about the surgery.
- B. Insist that the client look at the surgical site.
- C. Perform the wound care without involving the client.
- D. Tell the client that she will feel better soon.
Correct Answer: A
Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns
The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?
- A. I should take this medication with meals.'
- B. I need to report flulike symptoms to my doctor.'
- C. My doctor might order liver tests while I'm on this drug.'
- D. If I'm already having an asthma attack, this drug will not stop it.'
Correct Answer: A
Rationale: Zafirlukast should be taken on an empty stomach for better absorption. The other statements are correct: flulike symptoms and liver monitoring are relevant, and zafirlukast is not a rescue medication.
The nurse working in the emergency department realizes that it would be contraindicated to induce vomiting if someone had ingested which of the following?
- A. Ibuprofen
- B. Aspirin
- C. Vitamins
- D. Gasoline
Correct Answer: D
Rationale: Inducing vomiting after ingesting gasoline (a caustic substance) can cause aspiration or esophageal damage. Vomiting is safer for non-caustic substances like ibuprofen, aspirin, or vitamins.
The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in hot water daily.
- B. Inspect your feet daily for cuts or sores.
- C. Wear tight shoes to support your arches.
- D. Cut your toenails with rounded edges.
Correct Answer: B
Rationale: daily foot inspection is essential to detect early signs of injury or infection in diabetes