Nokea
The nurse is talking with a client with hypertension and hyperlipidemia who is receiving nifedipine and simvastatin. Which of the following statements by the client would require follow-up?
- A. I need to change positions slowly when I get out of bed.
- B. I take my medications daily with a glass of grapefruit juice.
- C. I drink a glass of red wine with dinner a few times each week.
- D. I have begun seasoning my foods with fresh herbs and spices.
Correct Answer: B
Rationale: Grapefruit juice (B) inhibits CYP3A4, increasing simvastatin levels and risk of toxicity. Orthostatic precautions (A), moderate wine (C), and herbs (D) are appropriate.
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Prior to administering a feeding, the nurse checks for placement of a feeding tube. What is the best way to do this?
- A. Check for residual
- B. Measure the pH of aspirated gastrointestinal fluid
- C. Inject 10 to 20 mL of air while auscultating over the epigastric area
- D. Ask the client to talk or hum
Correct Answer: B
Rationale: Measuring the pH of aspirated fluid (pH <5.5) confirms gastric placement, the most reliable method to prevent aspiration.
The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs?
- A. Create a strict daily schedule for the client while hospitalized
- B. Encourage the client to have peers visit while hospitalized
- C. Ensure parental presence during any client procedure
- D. Include the client as an active participant when planning care
- E. Support the client in discussing concerns about body image changes
Correct Answer: B,D,E
Rationale: Peer visits (B), active participation (D), and addressing body image (E) support a teen's psychosocial needs. Strict schedules (A) reduce autonomy, and parental presence (C) may not align with the teen's preferences.
The nurse is observing a staff member collecting a sputum specimen from a client with active tuberculosis. The nurse should intervene if the staff member is observed
- A. leaving unused supplies in the client's room after the procedure
- B. putting on clean gloves before putting on a protective gown
- C. leaving a dedicated, disposable stethoscope in the client's room
- D. putting on an N95 respirator mask and face shield before entering the client's room
Correct Answer: A
Rationale: Leaving supplies (A) in a TB room risks contamination. Gloves before gown (B), dedicated stethoscope (C), and N95 with face shield (D) are appropriate.
The best position for the client with a right total hip replacement is:
- A. With the right hip flexed 90°
- B. With the right hip flexed 35°
- C. Supine with pillows supporting the right leg
- D. Sims position with the right leg adducted
Correct Answer: C
Rationale: Supine with pillows supporting the leg prevents dislocation while maintaining alignment. Flexion or adduction risks complications.
A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?
- A. Ask about liver disease and give acetaminophen from the nurse's personal supply
- B. Check for allergies to drugs before giving acetaminophen from hospital stock
- C. Check the employee's blood pressure
- D. Refer employee to the employee's health care provider
Correct Answer: D
Rationale: Nurses cannot dispense medications without a prescription (A, B). Checking blood pressure (C) is irrelevant. Referring to a provider (D) ensures proper evaluation and treatment.