Nokea
The nurse is teaching a client with a new diagnosis of ulcerative colitis about mesalamine (Asacol). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any fever or sore throat
- C. Stop the medication if symptoms improve
- D. Avoid taking with meals
Correct Answer: B
Rationale: Fever or sore throat may indicate bone marrow suppression, a serious mesalamine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks relapse, and it can be taken with meals.
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The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Some increase in the serum hemoglobin
- D. A little decrease in the serum potassium
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
At an inpatient psychiatric unit, a 40-year-old woman insists on staying in her room and repeatedly comments to the nurse: 'Special agents are here. Maybe you are one.'
Which of the following responses, if made by the nurse, is BEST?
- A. You can trust me. There are no agents here.'
- B. You must feel afraid if you believe that, but there are no agents here.'
- C. No one here will hurt you. They are here to help you.'
- D. Agents? Tell me more about what you mean.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication. (1) nontherapeutic, fails to respond to feeling tone, trust builds through interactions (2) correct-patient experiencing delusion (persistent false belief), responds to feeling tone, acknowledges that patient believes it to be true, represents reality (3) statement of reassurance, but denies acceptance of patient's feelings (4) should not encourage patient to explain delusions, would serve to reinforce them
The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST?
- A. After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen her/him sleeping on duty three times.
- B. I saw my coworker downtown after work. S/he was acting really strange, like s/he didn't even recognize me.
- C. I think my coworker is stealing narcotics because s/he is always acting euphoric and seems high.
- D. I am sure my coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms.
Correct Answer: A
Rationale: Objective observations, such as increased patient pain medication needs and sleeping on duty, provide verifiable evidence for investigation. Options B, C, and D are subjective or speculative, reducing their credibility.
The home care nurse is instructing a client recently diagnosed with tuberculosis.
- A. What is the most important instruction for a client with tuberculosis?
- B. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
- C. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.
- D. The family should support the client to help reduce feeling of low self-esteem and isolation.
- E. The client will be required to take prescribed medication for a duration of 6-9 months.
Correct Answer: D
Rationale: Adherence to a 6-9 month medication regimen is critical to cure tuberculosis and prevent drug resistance. While respiratory precautions, family support, and masks are important, long-term medication compliance is the most essential for treatment success.
A client who is receiving hydralazine (Apresoline) q6h has a blood pressure of 90/60.
Which of the following nursing actions would be MOST appropriate?
- A. Withhold the medication.
- B. Check the urinary output.
- C. Administer the medication.
- D. Increase the potassium intake.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. (1) correct-BP of 90/60 is too low for an additional dose of medication, withholding the medication and checking with the doctor is appropriate (2) assessment, appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance