Nokea
The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?
- A. Notify the health care provider if your urine is red
- B. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication
- C. Wear eyeglasses instead of soft contact lenses while taking this medication
- D. You can stop taking the medications as soon as one sputum culture comes back normal
Correct Answer: C
Rationale: Rifampin can stain soft contact lenses orange-red, so wearing eyeglasses prevents this issue, making it a key instruction for adherence.
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The nurse is collecting data from a client with heart failure. The nurse notes that the client is agitated, has crackles bilaterally, and is reporting dyspnea and anxiety. The nurse should place the client in
- A. modified Trendelenburg position
- B. high Fowler position
- C. left Sims position
- D. supine position
Correct Answer: B
Rationale: High Fowler position optimizes lung expansion and reduces preload, alleviating dyspnea and crackles in acute heart failure exacerbation.
The nurse is teaching an adult who has a broken ankle that has been casted how to climb stairs. The nurse knows that the client understands how to climb up stairs when she does which of the following?
- A. While bearing weight on the unaffected leg, the client moves the crutches up to the next step followed by the affected leg and then the unaffected leg.
- B. While bearing weight on the unaffected leg, the client moves affected leg to the next step followed by the unaffected leg and the crutches.
- C. While bearing weight on crutches, the client moves the affected leg to the next step followed by the unaffected leg and the crutches.
- D. While bearing weight on crutches, the client moves the unaffected leg to the next step followed by the affected leg and the crutches.
Correct Answer: D
Rationale: To climb stairs, weight is borne on crutches, moving the unaffected leg first, then the affected leg and crutches, ensuring stability and safety using the stronger leg.
A client who has Type 1 diabetes mellitus is admitted for alcohol detoxification. A moderate sliding scale for insulin is ordered. How often should the nurse expect to take glucose levels?
- A. Every time medication is administered
- B. When the client is symptomatic
- C. Before meals and at bedtime
- D. Every two hours
Correct Answer: C
Rationale: Sliding scale insulin for Type 1 diabetes requires glucose checks before meals and at bedtime to adjust dosing, ensuring glycemic control.
The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.
- A. Check the client for abdominal distention and constipation
- B. Examine the catheter for kinks and obstructions
- C. Contact the client's health care provider
- D. Place the client in a side-lying position
- E. Flush the tubing with dialysate
Correct Answer: A,B,D
Rationale: Checking for distention/constipation (A), examining for catheter issues (B), and repositioning to a side-lying position (D) address common causes of outflow issues non-invasively.
The nurse hears another staff member talking in a crowded elevator about a client on the unit. The client is identified by name and details of illness. What action should the practical nurse take at this time?
- A. Report the behavior to the head nurse
- B. Report the behavior if it happens again
- C. Interrupt the conversation in the elevator
- D. Speak to the staff member when he/she gets off the elevator
Correct Answer: D
Rationale: Speaking to the staff member privately after the elevator ride addresses the HIPAA violation discreetly, promoting education and correction without immediate escalation.