Nokea
The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct in identifying which of the following medications can increase the risk for falls? Select all that apply.
- A. naproxen
- B. alprazolam
- C. bumetanide
- D. verapamil
- E. allopurinol
- F. thiamine
Correct Answer: B,C,D
Rationale: Alprazolam (benzodiazepine) causes sedation and dizziness, bumetanide (diuretic) can cause orthostatic hypotension, and verapamil (calcium channel blocker) can cause hypotension, all increasing fall risk. Naproxen, allopurinol, and thiamine do not significantly contribute to falls.
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The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 6 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each assessment finding, click to specify if the finding indicates that the client's condition has improved, not changed, or worsened.
- A. Toileting access
- B. Medication organization
- C. Urinary patterns
- D. Activity tolerance
- E. Lower extremities
- F. Bathroom lighting
Correct Answer: A,B,C:Improved;D,E,F:Unchanged
Rationale: Improved toileting access, medication organization, and urinary patterns indicate better management. Activity tolerance, lower extremity symptoms, and bathroom lighting remain unchanged.
The nurse is having difficulty locating a vein, to start intravenous therapy, on a client who is dark-skinned. Which of these devices or procedures may be of benefit to you at this time?
- A. A doppler
- B. A surgical vein cut down
- C. A transillumination device
- D. A sonography
Correct Answer: C
Rationale: A transillumination device uses light to visualize veins, aiding IV insertion in clients with dark skin or poor vein visibility. Doppler assesses blood flow, surgical cutdown is invasive, and sonography is not typically used for peripheral IVs.
The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life?
- A. Advocate for pain management unless life-threatening side effects occur.
- B. Advocate for pain management even if the life-threatening side effects hasten death.
- C. Prohibit the respiratory system from depressing drugs because this is euthanasia.
- D. Allow families to administer respiratory system depressing drugs to hasten death.
Correct Answer: B
Rationale: The ANA supports pain relief at end-of-life, even if side effects like respiratory depression hasten death, prioritizing comfort. Other options misalign with ethical standards.
The nurse has attended a staff education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed
- A. Placing a client with Cryptococcosis pneumonia on standard precautions.
- B. Wearing a particulate respirator mask (N95) when caring for a client with pharyngeal diphtheria.
- C. Removing alcohol-based hand rubs from a client's room who has mononucleosis.
- D. Placing a client who is incontinent of stool with Hepatitis A on contact precautions.
- E. Instructing a client with latent pulmonary tuberculosis to wear a surgical mask while in the hallway.
Correct Answer: A,D
Rationale: Cryptococcosis requires standard precautions, and Hepatitis A with incontinence requires contact precautions due to fecal-oral transmission. N95 is needed for TB, not diphtheria; hand rubs are safe for mononucleosis; latent TB does not require masking.
The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first?
- A. Obtain a fire extinguisher
- B. Close the bathroom door
- C. Remove the client from the room
- D. Activate the fire alarm
Correct Answer: C
Rationale: Removing the client from the room prioritizes safety in a potential fire hazard. Other actions follow after ensuring client safety.