Nokea
The nurse reinforces teaching for a client taking atorvastatin to call the health care provider if experiencing which symptom associated with a serious adverse effect of the medication?
- A. Diarrhea
- B. Headache
- C. Muscle aches
- D. Numbness in the feet
Correct Answer: C
Rationale: Muscle aches may indicate myopathy or rhabdomyolysis, serious atorvastatin side effects requiring immediate attention. Diarrhea, headaches, and numbness are less specific or unrelated.
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Because an adult is scheduled for a cystoscopy, the nurse should plan to do which of the following immediately prior to the procedure?
- A. Keep the client NPO for eight hours
- B. Ask the client about claustrophobia
- C. Ask the client about allergies to shellfish
- D. Encourage fluids
Correct Answer: C
Rationale: Cystoscopy may involve iodine-based contrast; shellfish allergies suggest iodine sensitivity, requiring verification. NPO is not needed, claustrophobia is irrelevant, and fluids are not prioritized immediately before.
Exhibit 1
Medication administration record
Allergies: No known drug allergies
Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100
Exhibit 2
Laboratory results and reference ranges
Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)
The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?
- A. Administer insulin lispro per protocol and insulin NPH
- B. Contact the client's health care provider
- C. Obtain a urine specimen to check for ketones
- D. Recheck the client's capillary blood glucose level
Correct Answer: B
Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.
Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?
- A. A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement
- B. A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
- C. A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement
- D. A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement
Correct Answer: B
Rationale: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement. When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.
The nurse is caring for a client diagnosed with polycythemia vera. Which statement by the client requires immediate follow-up?
- A. I am trying to find makeup to cover my unattractive, ruddy facial complexion
- B. I massage my sore leg to help bring the swelling down
- C. I take low-dose aspirin to relieve my occasional headaches
- D. My skin itches so severely, and no lotion or cream seems to help
Correct Answer: B
Rationale: Massaging a sore, swollen leg risks dislodging a clot in polycythemia vera, which predisposes to thrombosis. Ruddy complexion, aspirin use, and itching are expected but less urgent.
The nurse has taught the parent of a 6-year-old client with bacterial conjunctivitis how to administer ophthalmic medications. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. My child should look down at the floor while I administer the eye drops.
- B. My child should squeeze the eyes closed after I administer the eye drops.
- C. I will apply firm pressure to my child's eyes after I administer the eye ointment
- D. I will apply the eye ointment along my child's lower eyelids starting at the inner corner of the eyes
Correct Answer: D
Rationale: Appropriate administration of ophthalmic medications (eg, eye drops, ointments) protects eye structures and ensures appropriate distribution across the eye. Ophthalmic ointment should be administered along the lower eyelid, moving from the inner canthus to the outer canthus (inner corner to outer corner) (Option 4). In addition, the medication package (eg, eye dropper, tube of ointment) must not touch the eyes to prevent contamination.