Nokea
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.
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An infant is to be admitted with severe diarrhea. Which room assignment is best for this infant?
- A. A private room
- B. A room close to the nurse's station
- C. A room with a 2-year-old child who has a broken leg
- D. A room with another infant with severe diarrhea
Correct Answer: A
Rationale: A private room prevents transmission of infectious diarrhea to others. Proximity to the station, sharing with a non-infectious patient, or another diarrheal infant increases risks.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. A physical therapist to improve fine motor coordination
- C. An activity therapist from the community center
- D. Another client with diabetes mellitus and takes insulin
Correct Answer: B
Rationale: A physical therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
The mother of a 4-month-old infant calls the physician's office reporting that her child has a temperature of 101°F and a rash that is blanchable and doesn't itch. What does the LPN expect will be ordered for this child?
- A. Aspirin
- B. Ibuprofen
- C. Acetaminophen
- D. Antibiotics
Correct Answer: C
Rationale: Acetaminophen is safe for fever in infants, addressing the temperature while the non-itchy, blanchable rash is monitored, likely viral.
The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.
The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?
- A. Client on chemotherapy who started antibiotics today for cellulitis of the leg
- B. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours
- C. Client with diabetes who has nausea, abdominal pain, and vomiting
- D. Client with ulcerative colitis and diarrhea who has developed fever and vomiting
Correct Answer: B
Rationale: The client with resolved asthma exacerbation, not requiring oxygen or nebulizers for 12 hours, is stable and safe for discharge, unlike the others with active complications.