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What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The correct answer is B: Do not stop medication abruptly. Abruptly stopping propranolol can lead to rebound hypertension and potentially life-threatening complications. The nurse should emphasize the importance of gradual tapering under medical supervision to avoid adverse effects.
A: Having potassium levels checked is not directly related to propranolol use for hypertension management.
C: Changes in appetite are not specific to propranolol use and may not be a significant concern compared to abrupt cessation of the medication.
D: Resuming usual daily activities is important but not as crucial as the correct instruction to avoid abrupt discontinuation of propranolol.
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After a 3- month trail of dietary therapy, a client with type2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:
- A. 30 minutes before breakfast
- B. 30 minutes after dinner.
- C. in the midmorning
- D. at bedtime.
Correct Answer: A
Rationale: The correct answer is A: 30 minutes before breakfast. Glyburide is a sulfonylurea medication that stimulates insulin release from the pancreas, enhancing glucose uptake. Taking it before breakfast ensures peak insulin levels coincide with the postprandial glucose spike, aiding in glucose control throughout the day. Option B is incorrect as taking it after dinner may lead to hypoglycemia during sleep. Option C is incorrect as midmorning is not an optimal time for a sulfonylurea dose. Option D is incorrect as taking it at bedtime may also increase the risk of hypoglycemia overnight.
A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?
- A. Health status NursingStoreRN
- B. Health behavior
- C. Psychological self-control
- D. Health service utilization
Correct Answer: B
Rationale: The correct answer is B: Health behavior. Evaluating the patient's demonstration of self-injection assesses their ability to perform a specific health-related action. This choice focuses on the patient's actions and behaviors related to their health, aligning with the scenario provided.
Choice A: Health status is incorrect because it refers to the patient's current physical condition, not their ability to perform a specific health action.
Choice C: Psychological self-control is incorrect as it pertains to the patient's ability to regulate their emotions and impulses, not their ability to self-administer injections.
Choice D: Health service utilization is incorrect as it relates to the frequency and pattern of healthcare services used by the patient, not their ability to perform a specific health behavior.
The nurse notes that a client’s wound has not improved despite consistent wound care as outlined in the care plan. What should the nurse do next?
- A. Reassess the wound and client’s condition.
- B. Discontinue the current care plan.
- C. Increase the frequency of wound dressing changes.
- D. Refer the client to a specialist immediately.
Correct Answer: A
Rationale: Step 1: Reassessing the wound and client's condition allows the nurse to identify any factors contributing to the lack of improvement.
Step 2: It helps determine if the current care plan needs modifications or if there are underlying issues affecting healing.
Step 3: This step ensures a comprehensive evaluation before making any changes to the care plan, promoting evidence-based practice.
Step 4: Choosing this option aligns with the nursing process of assessment, which is crucial for making informed decisions in client care.
Summary:
Option A is correct as it emphasizes the importance of reassessment to gather more information and make informed decisions. Discontinuing the care plan (Option B) without assessment can be harmful. Increasing dressing changes (Option C) may not address the underlying issue. Referring immediately (Option D) may be premature without reassessment.
A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse’s BEST response?
- A. move the right crutch ahead, then follow with the left foot
- B. move both crutches forward together, then swing legs through
- C. move the left crutch and the right foot forward together
- D. move both crutches and the weaker leg forward at the same time
Correct Answer: A
Rationale: The correct answer is A because in the four-point gait with partial weight bearing, the client should move the right crutch ahead first to provide support and stability, followed by the left foot. This sequence ensures proper weight distribution and balance. Moving both crutches together (B) may compromise stability. Moving the left crutch and right foot together (C) may cause uneven weight distribution. Moving both crutches and weaker leg together (D) may not provide adequate support for the weaker leg.
A patient who has just had a TURP asks his nurse to explain why he has to have the bladder irrigation because it seems to increase his pain. Which of the following explanations by the nurse is best?
- A. “The bladder irrigation is needed to stop the bleeding in the bladder.”
- B. “Antibiotics are being administered into the bladder to prevent infection.”
- C. “The irrigation is needed to keep the catheter from becoming occluded by blood clots.”
- D. “Normal production of urine is maintained with the irrigations until healing can occur.”
Correct Answer: C
Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure.
Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications.
Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow.
Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.