Nokea
The nurse is reinforcing teaching about home administration of sublingual nitroglycerin tablets to a client with stable angina. Which client statement indicates the need for further teaching?
- A. I can take 1 tablet every 5 minutes, up to 3 times, for chest pain.'
- B. I should call 911 if my chest pain isn't relieved by nitroglycerin.'
- C. I will call my doctor's office if I start experiencing chest pain at rest.'
- D. I will keep one bottle of nitroglycerin in the house and one in the car.'
Correct Answer: D
Rationale: Keeping nitroglycerin in a car (D) risks exposure to heat, reducing efficacy, requiring further teaching. Other statements (A, B, C) are correct.
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The nurse working on a pediatric oncology unit recognizes which as a personal coping strategy for remaining effective when caring for dying children?
- A. Attending a child's memorial service
- B. Avoiding expressing personal feelings of grief or loss directly with the family
- C. Ending personal contact with the deceased's family members after they leave the hospital
- D. Increasing length of daily exercise routines
Correct Answer: D
Rationale: Increasing exercise (D) is a healthy coping strategy to manage stress. Attending memorials (A), avoiding grief expression (B), or ending contact (C) may not promote long-term emotional resilience.
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
- A. Place pillows under the knees
- B. Use elastic stockings continuously
- C. Encourage range of motion and ambulation
- D. Massage the legs twice daily
Correct Answer: C
Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.
Laboratory results
Sodium
136-145 mEq/L
(136-145 mmol/L) 126 mEq/L
(126 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.8 mEq/L
(4.8 mmol/L)
Calcium
9.0–10.5 mg/dL
(2.25–2.62 mmol/L) 9.0 mg/dL
(2.25 mmol/L)
A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate?
- A. 0.45% sodium chloride IV
- B. Calcium gluconate
- C. Furosemide
- D. Sodium polystyrene sulfonate
Correct Answer: C
Rationale: Weight gain in heart failure suggests fluid retention. Furosemide (C), a diuretic, is anticipated to reduce fluid overload. Sodium chloride (A) worsens fluid retention, and calcium gluconate (B) and sodium polystyrene (D) address other conditions.
The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.
- A. Apple juice
- B. Chicken broth
- C. Cranberry juice
- D. Cream of chicken soup
- E. Unsweetened tea
- F. Vanilla ice cream
Correct Answer: A, B, C, E
Rationale: Clear liquids include apple juice (A), chicken broth (B), cranberry juice (C), and unsweetened tea (E). Cream of chicken soup (D) and ice cream (F) are not clear liquids.
A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching?
- A. My child may experience incontinence.'
- B. My child may seem confused afterwards.'
- C. My child may stare and seem inattentive.'
- D. My child will notice unusual odors prior to the event.'
Correct Answer: C
Rationale: Staring and inattention (C) are hallmark signs of absence seizures. Incontinence (A) and confusion (B) are more typical of other seizures, and odors (D) suggest an aura, not typical in absence seizures.