Nokea
The nurse prepares to reinforce teaching for a client with latent tuberculosis who is prescribed oral isoniazid. Which instructions should the nurse include? Select all that apply.
- A. Avoid drinking alcohol
- B. Expect body fluids to change color to red
- C. Report yellowing of skin or sclera
- D. Report numbness and tingling of extremities
- E. Take with aluminum hydroxide to prevent gastric irritation
Correct Answer: A,C,D
Rationale: Avoiding alcohol (A), reporting jaundice (C), and reporting neuropathy (D) address isoniazid's risks of hepatotoxicity and peripheral neuropathy.
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The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
- A. bounding pulse
- B. rapid respirations
- C. oliguria
- D. neck veins are distended
Correct Answer: C
Rationale: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.
The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to 'reach the itch.' What is the nurse's priority action?
- A. Offer the client a straw to reach the itch instead of a lead pencil
- B. Perform a peripheral neurovascular check of the casted extremity
- C. Pour a generous amount of baby powder or corn starch in the cast to reach the itch
- D. Review appropriate itch relief technique using the cool setting of a hair dryer
Correct Answer: D
Rationale: Using a hair dryer on a cool setting is a safe and effective way to relieve itching without risking skin damage or cast integrity, unlike inserting objects or powders.
The home health nurse is caring for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse determines the client is unresponsive and pulseless, and there are no other caregivers present. Which of the following actions should the nurse take next?
- A. Deliver 30 chest compressions.
- B. Activate the emergency response system.
- C. Locate an automated external defibrillator.
- D. Deliver 2 breaths using a bag valve device connected to the tracheostomy.
Correct Answer: B
Rationale: Activating the emergency response system ensures rapid assistance for a pulseless child, initiating the chain of survival in pediatric cardiac arrest.
The nurse is caring for an older client who had a cerebrovascular accident (CVA) several days ago. She is having trouble speaking. How should the nurse relate to this client?
- A. Encourage the client to speak and wait patiently while she tries
- B. Speak louder to the client
- C. Finish the client's sentences when she is having difficulty
- D. Tell the client to rest her voice for the next few days
Correct Answer: A
Rationale: Encouraging speech with patience supports recovery in aphasia post-CVA, unlike loud speech, finishing sentences, or voice rest, which hinder communication progress.
Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?
- A. A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessment, which should occur in longer than 3-month intervals
- B. A glycosylated hemoglobin is to be obtained at least two years
- C. A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment
- D. A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment
Correct Answer: A
Rationale: The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care for clients with poor glycemic control.