Nokea
The physician has ordered sublingual nitroglycerin for a client. Which of the following are contraindications for administration of sublingual or buccal medications? Select all that apply.
- A. Client is edentulous.
- B. Client has mild dementia.
- C. Mucous membranes are red and irritated.
- D. Client is dehydrated.
- E. Client has productive aphasia.
Correct Answer: C,D
Rationale: Red, irritated mucous membranes (C) and dehydration (D) impair sublingual absorption. Edentulous state (A), mild dementia (B), and aphasia (E) do not contraindicate sublingual administration.
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A child with achondroplasia will likely have which of the following physical characteristics?
- A. alopecia, failure to thrive, small face, recessed jaw
- B. enlarged hands and feet, skull expansion at fontanelle, enlarged tongue
- C. poor muscle tone, slanted eyes, single palmar crease
- D. dwarf stature, short fingers and toes, short proximal limbs
Correct Answer: D
Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.
The '5 A's' of smoking cessation intervention begin with which of the following?
- A. Advise all clients who smoke to stop smoking.
- B. Ask all clients about tobacco use at every visit.
- C. Assess clients' willingness to stop smoking.
- D. Assist the client to stop smoking.
Correct Answer: B
Rationale: The 5 A's begin with Ask (B), identifying tobacco use at every visit, followed by Advise, Assess, Assist, and Arrange.
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true of the collection of cultures for cytomegalovirus?
- A. Stool cultures are preferred for definitive diagnosis.
- B. Pregnant caregivers may obtain cultures.
- C. Collection of one specimen is sufficient.
- D. Accurate diagnosis depends on fresh specimens.
Correct Answer: D
Rationale: Fresh specimens are critical for accurate CMV culture results, as the virus is labile and degrades quickly.
The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?
- A. A pair of forceps
- B. A torque wrench
- C. A pair of wire cutters
- D. A screwdriver
Correct Answer: B
Rationale: A torque wrench is needed to adjust and maintain the tension of crutchfield tongs for cervical stabilization.
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
- A. You will be sitting for the examination procedure.
- B. Portions of the procedure will cause pain or discomfort.
- C. You will be asleep during the procedure.
- D. You will not be able to drink fluids for 24 hours following the study.
Correct Answer: B
Rationale: Renal biopsies may cause discomfort during needle insertion, and informing the client prepares them for the procedure.