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The nurse is teaching a client with a new diagnosis of depression about fluoxetine (Prozac). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report any suicidal thoughts.
- C. Stop the medication if mood improves.
- D. Avoid regular mental health follow-ups.
Correct Answer: B
Rationale: Suicidal thoughts are a serious fluoxetine side effect, requiring immediate reporting. Options A, C, and D are incorrect.
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The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has Vectors are not supported in text mode. Please provide the text content you want to include, and I'll help format it appropriately. to have the CBI. Which of the following responses by the nurse is BEST?
- A. The CBI prevents urinary stasis and infection.
- B. The CBI dilutes the urine to prevent infection.
- C. The CBI enables urine to keep flowing.
- D. The CBI delivers medication to the bladder.
Correct Answer: C
Rationale: continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
A Hispanic client in the postpartum period refuses the hospital food because it is 'cold.' The best initial action by the nurse is to
- A. Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes
- B. Ask the client what foods are acceptable or are unacceptable
- C. Encourage her to eat for healing and strength
- D. Schedule the dietitian to meet with the client as soon as possible
Correct Answer: B
Rationale: Ask the client what foods are acceptable or are unacceptable. Understanding cultural food preferences ensures appropriate dietary support.
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Which of the following symptoms is MOST important for the nurse to report to the next shift?
- A. Nausea with a small amount of vomitus.
- B. Pain of five on a scale of one to ten.
- C. Change in the location and character of pain.
- D. No known drug allergies.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority
A client who has been complaining of dysuria, urinary frequency, and discomfort in the suprapubic area.
After evaluating the results, the nurse should order a repeat urinalysis based on which of the following findings?
- A. Negative glucose.
- B. RBCs present.
- C. No WBCs or RBCs reported.
- D. Specific gravity 1.018.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates a bladder infection. (1) glucose increases during the inflammation process; it is not a primary component in determining urinary tract infections (2) not as complete a response as answer choice #3 (3) correct-with the client's complaints, WBCs and RBCs should be present; WBCs are a response to the inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and bleeding (4) indicates the concentration of the urine