Nokea
The nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches for angina. Which of the following statements by the client would require follow-up?
- A. I can apply a new patch to my arm or chest each day
- B. I should avoid placing the patch over areas with a lot of hair
- C. I should remove the patch at night to prevent tolerance
- D. I will apply the patch only when I experience chest pain
Correct Answer: D
Rationale: Nitroglycerin patches are for angina prevention, applied daily, not as-needed. Rotating sites, avoiding hair, and removing at night (patch-free interval) are correct.
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A young woman has routine blood work done at her prenatal appointment. The results indicate that she has a hemoglobin level of 10 g/dL. The nurse explains to her that this result is:
- A. high.
- B. insignificant.
- C. low.
- D. normal.
Correct Answer: C
Rationale: A hemoglobin of 10 g/dL is low (normal in pregnancy: 11-12 g/dL), indicating possible anemia, requiring further evaluation.
A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications?
- A. How to monitor blood pressure daily
- B. How to prevent constipation
- C. How to prevent itching
- D. How to prevent nausea
Correct Answer: B
Rationale: Constipation is a common, long-term complication of oxycodone, requiring preventive measures like fiber and fluids. Blood pressure monitoring, itching, and nausea are less critical long-term concerns.
Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?
- A. Tell the parents to bring the child to the clinic for further evaluation
- B. Refer the school officials to printed materials about this viral illness
- C. Inform the teacher that the child is receiving antibiotics for the rash
- D. Explain that this rash is not contagious and does not require isolation
Correct Answer: D
Rationale: Explain that this rash is not contagious and does not require isolation. Fifth Disease is not contagious once the rash appears, except in specific cases.
The nurse is discussing activities to promote language development with the parent of a 2-year-old. Which statement by the parent requires follow-up?
- A. I have dress-up clothes set out for my child to play with.
- B. I read brightly-colored picture books with rhymes with my child
- C. I set out a basket of toy cars when other children come to play
- D. I will enroll my child to play on a soccer team
Correct Answer: D
Rationale: Enrolling a 2-year-old in soccer is premature, as it does not directly promote language development and is not age-appropriate. Reading rhyming books and facilitating peer play with toys support language skills.
Exhibit 1
Vital signs
0800
Temperature 98.4 F (36.8 C)
Blood pressure 110/72 mm Hg
Heart rate 52/min
Respirations 16/min
Exhibit 2
Laboratory results
0800
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 40%
(0.4)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L) 14.0 g/dL
(140 g/L)
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 200,000/mm3
(200 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.0 mEq/L
(4.0 mmol/L)
Exhibit 3
Medication administration record
Allergies: No known drug allergies
Medications Time
Aspirin: 81 mg by mouth, daily 0900
Docusate sodium: 100 mg by mouth, daily 0900
Lisinopril: 5 mg by mouth, daily 0900
Metoprolol: 100 mg by mouth, twice daily 0900, 1700
Simvastatin: 20 mg by mouth, daily 2000
A client with ST segment elevation myocardial infarction is due for 0900 medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply.
- A. aspirin
- B. docusate sodium
- C. lisinopril
- D. metoprolol
- E. simvastatin
Correct Answer: A,C,D,E
Rationale: Aspirin (antiplatelet), lisinopril (ACE inhibitor), metoprolol (beta-blocker), and simvastatin (statin) are standard for STEMI to reduce clot formation, blood pressure, and cholesterol. Docusate is unrelated to STEMI management.