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The nurse should instruct the client to avoid which of the following drugs while taking metoclopramide hydrochloride (Reglan)?
- A. Antihypertensives.
- B. Anticoagulants.
- C. Alcohol.
- D. Cimetidine.
Correct Answer: C
Rationale: Alcohol can enhance the sedative effects of metoclopramide and worsen gastrointestinal symptoms, so it should be avoided.
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Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
- A. Administering oxygen every 2 hours.
- B. Turning the client every 4 hours.
- C. Administering sedatives to promote rest.
- D. Suctioning if cough is ineffective.
Correct Answer: D
Rationale: Suctioning clears secretions when coughing is ineffective in ARDS, maintaining airway patency. Oxygen delivery, turning, and sedatives are supportive but less direct for airway clearance.
A client who has undergone a mastectomy is worried about her body image and its impact on her sexual relationship. The nurse should suggest:
- A. Wearing a prosthesis during intimate moments.
- B. Avoiding discussions about her surgery with her partner.
- C. Focusing only on non-physical aspects of intimacy.
- D. Ignoring her concerns as they are temporary.
Correct Answer: A
Rationale: Wearing a prosthesis can help the client feel more confident about her body image during intimate moments, supporting her sexual relationship.
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Encourage the client to cough and deep breathe.
- C. Auscultate the lungs to detect abnormal breath sounds.
- D. Contact the physician.
Correct Answer: D
Rationale: Sudden dyspnea, tachypnea, and chest discomfort suggest a pulmonary embolism, a medical emergency. Contacting the physician first ensures rapid intervention. Elevating the bed, encouraging coughing, or auscultating lungs delays critical treatment.
A nurse is admitting a client who has been admitted with a diagnosis of upper GI bleeding to the hospital. The nurse should assess the client for which of the following? Select all that apply.
- A. Dry, flushed skin.
- B. Decreased urine output.
- C. Tachycardia.
- D. Widening pulse pressure.
- E. Rapid respirations.
- F. Thirst.
Correct Answer: A,B,C,E,F
Rationale: Upper GI bleeding can lead to hypovolemia, causing dry, flushed skin, decreased urine output, tachycardia, rapid respirations, and thirst. Widening pulse pressure is not typically associated with hypovolemia.
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6°F (38.1°C). Which of the following would be a priority outcome for this client?
- A. Prevention of urinary tract complications.
- B. Alleviation of nausea.
- C. Alleviation of pain.
- D. Maintenance of fluid and electrolyte balance.
Correct Answer: C
Rationale: Severe flank pain is the most urgent issue, making pain alleviation the priority outcome to ensure client comfort and stability.