Nokea
The nurse is talking with a client with stable angina who has a prescription for sublingual nitroglycerin. Which of the following statements by the client would require follow-up?
- A. I shall sit down if possible before taking this medication to prevent dizziness.
- B. I may experience flushing or a headache when taking this medication.
- C. I will avoid taking the medication with grapefruit juice.
Correct Answer: C
Rationale: Nitroglycerin is not contraindicated with grapefruit juice (C), indicating a misunderstanding. Sitting down (A) prevents falls from hypotension, and flushing/headache (B) are expected side effects, both correct.
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The nurse enters the room of a client who had major abdominal surgery 1 week ago and notes dehiscence and evisceration of the surgical incision. The nurse should immediately place the client in the
- A. Low Fowler position with the knees bent
- B. Prone position
- C. Supine position with the head of the bed flat
- D. Side-lying position
Correct Answer: A
Rationale: Low Fowler with knees bent (A) reduces abdominal tension, preventing further evisceration while awaiting surgical intervention. Prone (B), supine flat (C), or side-lying (D) increase strain or risk organ protrusion.
The practical nurse on the mental health unit is planning care with the registered nurse. Which client should be seen first?
- A. Client with bulimia nervosa who has been in the restroom for the past hour since breakfast
- B. Client with major depressive disorder who has suicidal ideation with a plan and is on one-to-one observation
- C. Client with obsessive-compulsive disorder who refuses to attend group therapy because it interrupts handwashing ritual
- D. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at caregivers
Correct Answer: B
Rationale: Suicidal ideation with a plan (B) poses an immediate safety risk, requiring urgent assessment despite one-to-one observation. Bulimia (A) and schizophrenia (D) behaviors need monitoring but are less acute. OCD refusal (C) is a lower priority, as it does not indicate immediate harm.
Which of the following indicates that the client taking an anticoagulant needs further teaching?
- A. The client states that he will report bruising
- B. The client states that he eats green, leafy vegetables at least three times weekly
- C. The client states that he will return to the doctor's office for scheduled lab work
- D. The client states that his insulin dose might have to be adjusted while he is taking an anticoagulant
Correct Answer: B
Rationale: Green, leafy vegetables are high in vitamin K, which can counteract anticoagulants like warfarin, so consistent intake or dietary counseling is needed.
The nurse prepares a client for discharge following a vasectomy. The client asks, 'When can I have sexual intercourse with my wife without using a condom?' What is the best response by the nurse?
- A. Discontinue alternative birth control after at least 5 ejaculations.
- B. There is no need to use alternative birth control following today's procedure.
- C. Use alternative birth control for 6 months following today's procedure.
- D. Use alternative birth control until your physician confirms the absence of sperm in a semen analysis.
Correct Answer: D
Rationale: A vasectomy requires confirmation of azoospermia via semen analysis, typically after 6-12 weeks or 15-20 ejaculations, to ensure sterility. Alternative birth control (C) is needed until this confirmation. Immediate unprotected intercourse (A) risks pregnancy, and 6 months (B) is unnecessarily long.
Which client is most at risk for methicillin-resistant Staphylococcus aureus infection?
- A. 15-year-old student athlete in the emergency department with a closed femur fracture
- B. 46-year-old client on the medical-surgical unit after a laparoscopic appendectomy
- C. 72-year-old client who received a permanent pacemaker 24 hours ago
- D. 80-year-old client with a hemodialysis catheter who lives in a long-term care facility
Correct Answer: D
Rationale: The 80-year-old with a hemodialysis catheter in a long-term care facility (D) is at highest risk for MRSA due to invasive devices, frequent healthcare exposure, and communal living. Others (A, B, C) have lower risk profiles.