Nokea
The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective?
- A. Driving is not recommended until I stop taking this medication.
- B. If I experience a panic attack I should take an extra dose of medication.
- C. It will be 2-4 weeks before I feel the full effect of this medication.
- D. Withdrawal symptoms will occur if I abruptly stop taking this medication.
Correct Answer: C
Rationale: Buspirone takes 2-4 weeks for full effect, indicating effective teaching. Extra doses are unsafe, driving is generally allowed, and withdrawal is minimal.
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The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action?
- A. Blood-tinged stain on the inner aspect of the cast
- B. Capillary refill of 2 seconds on the affected extremity
- C. Mild swelling of toes on the right foot
- D. Pain of 9/10 an hour after a dose of morphine
Correct Answer: D
Rationale: Severe pain (9/10) despite recent morphine suggests complications like compartment syndrome, requiring immediate action. Other findings are less urgent.
An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?
- A. Apical heart rate is 62/min
- B. Blood sugar level is 240 mg/dL (13.3 mmol/L)
- C. Client is taking 20 mg fluoxetine daily
- D. Serum creatinine is 2.3 mg/dL (203 µmol/L)
Correct Answer: D
Rationale: Elevated serum creatinine (2.3 mg/dL) indicates renal impairment, which can lead to digoxin accumulation, necessitating frequent monitoring.
The nurse is making a home visit to the mother of an 8-lb baby boy born five days ago. Which observation indicates that the mother understands the care of the newborn?
- A. The mother is concerned about the fact that the baby has a soft stool after every breast feeding.
- B. The mother gives the baby a sponge bath but does not put him in a tub.
- C. The mother cleans the circumcised penis with alcohol when changing the diaper.
- D. The mother nurses the baby hourly.
Correct Answer: B
Rationale: Sponge baths are appropriate for newborns until the umbilical cord falls off, indicating proper care. Soft stools are normal, alcohol may irritate circumcision sites, and hourly nursing is excessive.
The nurse is preparing to administer scheduled medications to assigned clients. Which of the following medications should the nurse hold for clarification prior to administering?
- A. magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.41 mmol/L)
- B. calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L)
- C. clopidogrel for a client with a platelet count of 70,000/mm³ (70 × 10â¹/L)
- D. metformin for a client with a hemoglobin A1c level of 11%
Correct Answer: C
Rationale: Clopidogrel increases bleeding risk in a client with low platelets (70,000/mm³), requiring clarification. The other medications align with the clients' conditions.
The nurse is caring for a woman whose husband beats her regularly. Which is the most important long-term goal for this woman?
- A. Provide a long-term support group
- B. Help her feel like a survivor
- C. Point out the ways she behaved
- D. Be able to blame the abuser
Correct Answer: B
Rationale: Feeling like a survivor empowers the woman, fostering resilience and self-efficacy, the most important long-term goal in domestic violence recovery.