Nokea
While teaching the client about the importance of prenatal vitamins.
The nurse should tell the client to take the vitamins
- A. with orange juice at bedtime.
- B. at breakfast with coffee.
- C. with milk at lunch.
- D. with water at dinner.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-taking the vitamins with something acidic increases the absorption of iron, taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep (2) not the best way to take prenatal vitamins (3) not the best way to take prenatal vitamins (4) not the best way to take prenatal vitamins
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The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units at bedtime. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue in the morning.
- B. Sweating and shakiness at night.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin. Options A, C, and D are less urgent.
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
- A. You think that someone wants to poison you?
- B. Why do you think the food is poisoned?
- C. These feelings are a symptom of your illness.
- D. You're safe here. I won't let anyone poison you.
Correct Answer: A
Rationale: You think that someone wants to poison you? This acknowledges the client's perception, opening discussion and expressing doubt.
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture.
- A. What is the most important nursing care plan inclusion for an elderly client post-femoral fracture repair?
- B. Eat a high-protein, low-residue diet.
- C. Lie on her unoperated side.
- D. Exercise her arms and legs.
- E. Cough and deep breathe.
Correct Answer: D
Rationale: Coughing and deep breathing prevent respiratory complications like pneumonia, a significant risk due to immobility post-surgery. A high-residue diet prevents constipation, positioning varies, and exercises are secondary to respiratory care.
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Creatinine 2.0 mg/dL.
- B. Heart rate of 80 bpm.
- C. Blood pressure of 120/80 mmHg.
- D. Temperature of 99.5°F (37.5°C).
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal or less concerning: heart rate 80 bpm, blood pressure 120/80 mmHg, and temperature 99.5°F are stable.
A client receiving cromolyn sodium (Intal).
Which of the following statements, if made by the client to the nurse, indicates that teaching has been successful?
- A. I will take the medicine with my meals.
- B. It is important that I take the medication before going to bed.
- C. If I experience respiratory distress, I will take the medicine.
- D. I will take the medicine before I begin any vigorous exercise.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate information (2) inappropriate information (3) cromolyn sodium is not an antihistamine agent, an antiinflammatory, or a bronchodilator, does nothing for a client in respiratory distress (4) correct-cromolyn sodium (Intal) is used to prevent the release of histamine and other allergy-triggering substances