Nokea
The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.
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The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.
- A. I will apply moisturizing lotion on my legs every day.
- B. I will elevate my legs at night when I am sleeping.
- C. I will keep my legs below heart level when sitting.
- D. I will start walking outside with my neighbor.
- E. I will use a heating pad to promote circulation.
Correct Answer: A,C,D
Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.
The nurse is observing the parent feed a 3-month-old diagnosed with gastroesophageal reflux. Which action by the parent indicates that further teaching is necessary?
- A. The parent does not push the infant to finish the bottle
- B. The parent engages the infant in active play after the feeding
- C. The parent interrupts the feeding to burp the infant
- D. The parent supports the infant upright during the feeding
Correct Answer: B
Rationale: Active play post-feeding can worsen reflux. Not forcing the bottle , burping , and upright positioning are appropriate.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
Lab results indicate that the client's serum aminophylline level is 17 mcg/mL. The nurse recognizes that the aminophylline level is:
- A. Within therapeutic range
- B. Too high and should be reported
- C. Questionable and should be repeated
- D. Too low to be therapeutic
Correct Answer: A
Rationale: The therapeutic range for aminophylline is typically 10-20 mcg/mL. A level of 17 mcg/mL is within this range, so no action is needed. Answer B is incorrect as the level is not too high. Answer C is unnecessary as the level is clearly therapeutic. Answer D is incorrect as the level is not too low.
A throat culture is ordered for an adult who has a sore throat. The nurse asks the client if he has taken any medications to treat himself. Which medication, if reported by the client, would be of greatest concern to the nurse?
- A. Aspirin
- B. A throat lozenge
- C. Acetaminophen
- D. An antibiotic
Correct Answer: D
Rationale: Antibiotics can alter throat culture results by reducing bacterial growth, potentially leading to a false negative, the greatest concern.