Nokea
The nurse is teaching a client with a new diagnosis of glaucoma about timolol (Timoptic) eye drops. Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any shortness of breath.
- C. Use the drops every 4 hours.
- D. Avoid blinking after administration.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bronchospasm; shortness of breath requires reporting. Options A, C, and D are incorrect.
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The nurse is supervising care given to clients on a medical/surgical unit.
The nurse should intervene if which of the following is observed?
- A. A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
- B. A nurse injects insulin through a single-lumen percutaneous central catheter for client receiving total parenteral nutrition.
- C. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
- D. A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Correct Answer: C
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) appropriate procedure, prevents airborne contamination (2) insulin is the only medication that can be given, compatible with TPN (3) correct-applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur (4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
The nurse is teaching a client with a new diagnosis of osteoporosis about alendronate (Fosamax). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication first thing in the morning.
- B. I should remain upright for 30 minutes after taking it.
- C. I should take it with a full glass of water.
- D. I should take it with my calcium supplement.
Correct Answer: D
Rationale: Taking alendronate with a calcium supplement is incorrect, as it reduces absorption; they should be taken at different times. Options A, B, and C are correct: morning dosing, remaining upright, and taking with water minimize esophageal irritation and maximize absorption.
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant.
- A. Which client is appropriate for the nursing assistant to care for?
- B. A client with Alzheimer’s requiring assistance with feeding.
- C. A client with osteoporosis complaining of burning on urination.
- D. A client with scleroderma receiving a tube feeding.
- E. A client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: Nursing assistants can care for clients with standard, unchanging procedures like feeding an Alzheimer’s patient. Clients with urinary symptoms, tube feedings, or unstable respirations require RN or LPN assessment and intervention.
The nurse is performing teaching for a client being discharged on clozapine (Clozaril).
Which of the following client statements indicates to the nurse that teaching has been successful?
- A. I need to call my doctor in a few weeks for a follow-up appointment.'
- B. I need to keep my doctor's appointment next week for a blood Test .'
- C. I can take over-the-counter sedatives if I have trouble sleeping.'
- D. I can drink alcohol as long as I drink in moderation.'
Correct Answer: B
Rationale: Strategy: 'Teaching has been successful' indicates a correct response. (1) follow routine schedule (2) correct-Clozaril causes agranulocytosis; requires weekly WBC; teach client to report early signs of infection (3) check with physician before taking any OTC medication (4) check with physician before ingesting alcohol