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 in the emergency department is caring for a client who has a small piece of wood penetrating the right eye. Which of the following actions should the nurse take?
- A. Flush the eye
- B. Remove the object with tweezers.
- C. Stabilize the object.
- D. Administer optic antibiotic ointment.
Correct Answer: C
Rationale: Stabilizing the object prevents further damage until surgical removal. Flushing , removing , or applying ointment risks worsening the injury.
The nurse has received a prescription from the health care provider to administer 94 mg of methylprednisolone via IV push. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: Calculate: 94 mg ÷ 125 mg/2 mL = 1.504 mL. Syringe 3 (typically 1.5 mL) is closest. Syringes 1, 2, and 4 are not specified but assumed incorrect volumes.
A client with chronic pancreatitis is receiving Pancreatin. Which of the following observations is most indicative that the drug treatment is having the desired effect?
- A. The client's appetite is improved.
- B. The client's weight loss is greater than 10 pounds.
- C. The client's stools contain less fat and occur with less frequency.
- D. The client's tissue bruises less easily.
Correct Answer: C
Rationale: Pancreatin replaces pancreatic enzymes, aiding fat digestion. Reduced fat in stools and less frequent bowel movements indicate effective treatment. Appetite improvement is secondary, weight loss is undesirable, and bruising is unrelated.
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- A. Elevated blood glucose
- B. Elevated platelet count
- C. Elevated creatinine clearance
- D. Elevated hepatic enzymes
Correct Answer: D
Rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets. Elevated hepatic enzymes are a key finding, so D is correct. Answers A, B, and C are not associated with HELLP syndrome.
A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings?
- A. A reported history of recent trauma
- B. Abdominal bruising
- C. External signs of trauma
- D. Irritability and vomiting
Correct Answer: D
Rationale: Shaken baby syndrome often presents with irritability and vomiting due to intracranial injury, without external trauma , abdominal bruising , or reported trauma .
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