Nokea
The nurse is reinforcing teaching with a client who has a new prescription for sublingual nitroglycerin. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I am able to take nitroglycerin with my prescribed vardenafil
- B. I will stop taking nitroglycerin if I experience a headache or flushing
- C. I can keep a few nitroglycerin tablets in a plastic bag in case I need them while I am away from home
- D. I should take 1 nitroglycerin tablet every 5 minutes, up to 3 doses, if I am experiencing chest pain
Correct Answer: D
Rationale: Many clients lack knowledge about the proper administration, storage, and side effects of nitroglycerin (NTG). Client teaching can prevent many emergency department visits for chest pain caused by stable angina. Clients should be taught to take 1 tablet every 5 minutes, up to 3 doses. Emergency medical services should be called if pain does not improve or worsens 5 minutes after the first tablet is taken. Previously, clients were taught to call after the third dose was taken, but new evidence suggests this causes a significant delay in treatment
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The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?
- A. Answer the bell quickly each time she rings
- B. Say, 'I do not have time to be in your room constantly.'
- C. Say, 'Why are you so upset?'
- D. Say, 'You seem concerned about something.'
Correct Answer: D
Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.
The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up?
- A. Gum bleeding
- B. Lung sounds
- C. Homan's sign
- D. Generalized weakness
Correct Answer: A
Rationale: The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients.
The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ('knocked out'). After recovering the tooth, the initial response should be to
- A. Rinse the tooth in water before placing it in the socket
- B. Place the tooth in a clean plastic bag for transport to the dentist
- C. Hold the tooth by the roots until reaching the emergency room
- D. Ask the child to replace the tooth even if the bleeding continues
Correct Answer: A
Rationale: Rinse the tooth in water before placing it in the socket. Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth in its socket within 30 minutes, avoiding contact with the root.
A primigravida arrives at the labor unit stating that she is having contractions. Which statement describes the presence of true contractions?
- A. True contractions begin in the lower abdomen.
- B. True contractions have a consistent frequency.
- C. True contractions lessen with physical activity.
- D. True contractions are inconsistent in frequency.
Correct Answer: B
Rationale: True contractions have a consistent frequency , becoming regular and stronger. They start in the back or upper abdomen (A is incorrect), intensify with activity (C is incorrect), and are regular (D is incorrect).
A 52-year-old woman who has thyroid cancer is treated with radioactive iodine (Iodotope). What should be included in the nursing care plan following administration of the drug? Select all that apply.
- A. Tell the client not to eat or drink anything for four hours.
- B. Tell the client not to sleep in the same room with anyone for seven days following administration.
- C. Save the client's urine in a lead container for 48 hours.
- D. Limit contact with the client to 30 minutes per person per shift on day 1.
- E. Assign client to a single room.
- F. Tell client to report weight gain and severe fatigue to health care provider.
Correct Answer: B,D,E,F
Rationale: Radioactive iodine requires isolation in a single room, limited contact (30 minutes/shift), separate sleeping for 7 days, and reporting symptoms like fatigue or weight gain (hypothyroidism). NPO or urine storage are not standard.