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The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication at the first sign of a headache.
- B. I should avoid driving after taking this medication.
- C. I should report chest pain to my doctor.
- D. I should take this medication every morning to prevent headaches.
Correct Answer: D
Rationale: Taking sumatriptan daily to prevent migraines is incorrect, as it is used to abort acute attacks, not for prophylaxis. Options A, B, and C are correct: early use maximizes efficacy, sedation may impair driving, and chest pain may indicate vasoconstriction.
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A client with chronic obstructive pulmonary disease is receiving $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$ via nasal cannula. He is anxious and short of breath, and his mental status is clouded. The nurse should:
- A. Increase the $\mathrm{O}_2$ to $6 \mathrm{~L}/\mathrm{min}$.
- B. Monitor for signs of impending respiratory failure.
- C. Maintain the $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$, but increase the humidity.
- D. Check the vital signs and oxygen saturation level.
Correct Answer: D
Rationale: Checking vital signs and oxygen saturation assesses the cause of symptoms (e.g., hypoxia, hypercapnia). Increasing O2 risks CO2 retention in COPD. Monitoring is passive. Humidity is secondary.
A patient is scheduled for electro-convulsive therapy treatment scheduled in the morning. What must the evening nurse do to provide the client ECT treatment possible?
- A. Patient signs an informed consent form
- B. Patient is given morning medications
- C. Patient gets a good night's sleep
- D. Patient has a good breakfast
Correct Answer: A
Rationale: An informed consent is required prior to surgery.
The nurse is caring for a client with a history of chronic venous insufficiency.
- A. Which intervention is most effective for a client with chronic venous insufficiency?
- B. Apply compression stockings.
- C. Encourage bed rest.
- D. Administer diuretics.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Compression stockings improve venous return, reducing edema and stasis in chronic venous insufficiency. Bed rest is discouraged, diuretics are not primary, and head elevation is irrelevant.
The nurse is caring for a client with a history of depression.
- A. Which client statement indicates a positive response to antidepressant therapy?
- B. I feel like my old self again.'
- C. I don’t need to take the medication anymore.'
- D. I’m sleeping more than usual.'
- E. I still feel sad most of the time.'
Correct Answer: A
Rationale: Feeling like their old self indicates improved mood and function, a positive response to antidepressants. Stopping medication prematurely, excessive sleep, or persistent sadness suggest inadequate response or side effects.
A cooling blanket is ordered for an adult client who has a temperature of 106°F. What nursing action is essential because the client has a cooling blanket?
- A. Keep a padded tongue blade at the bedside.
- B. Turn every two hours.
- C. Apply ice to the groin area.
- D. Cover with a sheet and blanket.
Correct Answer: B
Rationale: Turning every two hours prevents skin breakdown from prolonged cooling blanket contact. Tongue blades, ice, or heavy coverings are inappropriate.