Nokea
The nurse is teaching a client with a new diagnosis of hypertension about lisinopril (Prinivil). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report a persistent dry cough.
- C. Stop the medication if blood pressure is normal.
- D. Avoid regular blood pressure checks.
Correct Answer: B
Rationale: A persistent dry cough is a common lisinopril side effect, requiring reporting. Options A, C, and D are incorrect.
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A five-year-old boy in the playroom.
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a five-year-old boy?
- A. The boy plays with a large truck with another child.
- B. The boy talks on a toy telephone and imitates his father.
- C. The boy works on a puzzle with several other children.
- D. The boy holds and cuddles a large stuffed animal.
Correct Answer: B
Rationale: Strategy: Picture the child. (1) play begins to be cooperative at this age (2) correct-imitative behavior seen at this age (3) too advanced for this age (4) too regressed for this age
Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
- A. Sit in a low chair for ease in getting up to use the walker.
- B. Make sure rubber caps are in place on all four legs of the walker.
- C. You will begin weight-bearing on the affected hip soon.
- D. Practice tying your own shoes before you begin ambulating.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct-intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks
The nurse is to administer a nasogastric tube feeding to a client. Which action is essential prior to administering the feeding?
- A. Position the client in supine position.
- B. Aspirate contents from the nasogastric tube and check the pH.
- C. Check the client's vital signs.
- D. Ask the client if she feels full.
Correct Answer: B
Rationale: Aspirating and checking pH confirms nasogastric tube placement in the stomach, preventing aspiration during feeding.
A six-year-old boy comes to the outpatient clinic for a routine exam. His mother is concerned because her son often talks to an 'imaginary best friend.'
The nurse should advise the mother to
- A. insist that her son play more often with other children.
- B. tell her son that this friend is not a real person.
- C. allow her son to engage in imaginary play.
- D. encourage her son to explain his friend to her.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) doesn't recognize play with imaginary friends as normal developmental state (2) may create anxiety in child (3) correct-normal for 4- to 6-year-old children (4) may create anxiety in child
A client with clotting disorder has an order to continue Lovenox (Enoxaparin) injections after discharge. In assessing the client's readiness for teaching, the most important factor for the nurse to assess is the client's:
- A. Prior knowledge of anticoagulants and their role in controlling his disease
- B. Willingness to learn about injection techniques and site selection
- C. Adaptation to the need for daily injections to control his symptoms
- D. Overall intelligence and developmental level
Correct Answer: B
Rationale: Willingness to learn is critical for effective teaching about self-administering injections. Knowledge, adaptation, and intelligence are secondary.