Nokea
The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?
- A. I should brush my teeth regularly.
- B. I should report any skin rashes to my doctor.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.
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The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Magnesium 2.0 mEq/L.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.
A man is seen in the outpatient clinic for treatment of hypertension. The client expresses concern to the nurse that his wife has been unemployed for more than six months. He is afraid that soon they will be unable to pay their rent.
Which of these responses by the nurse would be BEST?
- A. These things always have a way of working themselves out.'
- B. It's important for your health that you not worry too much.'
- C. You're worried that you won't be able to pay the rent?'
- D. A social worker might be able to help you with this problem.'
Correct Answer: C
Rationale: Strategy: 'BEST' indicates there may be more than one response you will like. Remember therapeutic communication. (1) minimizes client's concerns (2) minimizes client's concerns and places pressure on client to avoid feelings (3) correct-reflective response, would encourage discussion of feelings and concerns (4) passing the buck, nontherapeutic
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions should the nurse prioritize?
- A. Encourage log-rolling when repositioning
- B. Administer pain medication as needed
- C. Keep the head of the bed elevated 45 degrees
- D. Monitor the surgical drain for output
Correct Answer: A
Rationale: Log-rolling maintains spinal alignment, preventing complications post-laminectomy. Options B, C, and D are secondary: pain management is routine, 45-degree elevation is excessive, and drain monitoring is less urgent.
The nurse is caring for a client receiving chemotherapy who is experiencing neutropenia. Which intervention would be most appropriate to recommend for inclusion in the client's plan of care?
- A. Assess the client's temperature every 4 hours due to risk of hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct the client in the use of a soft toothbrush.
- D. Assess the client for hematuria.
Correct Answer: B
Rationale: Neutropenia increases the risk of infection due to low neutrophil counts. Avoiding large crowds and sick individuals minimizes exposure to pathogens, making B the most appropriate intervention. Answer A is incorrect as hypothermia is not a primary concern. Answer C, while relevant for preventing mucosal bleeding, is less critical than infection prevention. Answer D is unrelated to neutropenia.
The nurse is caring for a client who had a cystoscopy earlier in the day. Which symptom from the client is of greatest concern to the nurse?
- A. Complaint of back pain
- B. Tea-colored urine
- C. Leg cramps
- D. Pink-tinged urine
Correct Answer: A
Rationale: Back pain post-cystoscopy may indicate complications like renal injury or infection, requiring urgent evaluation. Hematuria (tea/pink urine) is expected, and leg cramps are less concerning.