Nokea
A 50-year old man who attends an outpatient clinic is taking chlorpromazine hydrochloride (Thorazine) 100 mg tid. He reports to the nurse that he is sleeping through the day.
What should the nurse do?
- A. Contact the physician to change the dose to 100 mg bid.
- B. Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs.
- C. Instruct the man to take frequent naps during the day.
- D. Encourage the man to be more active during the day.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) 300-400 mg/day is needed to treat psychosis (2) correct-will reduce daytime sedation (3) won't decrease sedation from medication (4) won't decrease sedation from medication
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The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be most important for the nurse to make which of the following statements?
- A. Take this medication with food.
- B. Take this medication one hour before meals.
- C. Take this medication one hour after meals.
- D. Take this medication with orange juice.
Correct Answer: A
Rationale: reduces GI upset
The daughter of a 70-year-old patient with cancer asks the nurse, 'Do you believe in euthanasia?' Which of the following responses by the nurse is BEST?
- A. I think that each person has to decide this issue for herself.
- B. My religion is opposed to euthanasia.
- C. What are your thoughts about euthanasia?
- D. Did you see the TV program about euthanasia last night?
Correct Answer: C
Rationale: open-ended question, allows client to verbalize
The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas ring and Pearson attachment. The physician orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 cc. During the nurse's shift, the client drinks 700 cc of fluids and voids 400 cc. The nurse should record which of the following on the client's intake and output sheet?
- A. Intake: 2,700 cc; output: 400 cc.
- B. Intake: 2,700 cc; output: 2,200 cc.
- C. Intake: 700 cc; output: 400 cc.
- D. Intake: 2,700 cc; output: 1,800 cc.
Correct Answer: B
Rationale: intake and output
The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST important for the nurse to include which of the following as a part of his discharge planning?
- A. Referral to a social service agency for assistance with housing.
- B. Referral to an aftercare center in the community.
- C. Participation in Alcoholics Anonymous (AA) meetings with a sponsor.
- D. A prescription for an antidepressant medication.
Correct Answer: C
Rationale: self-help groups have greatest success rate as a sustained support system in the community
The nurse is leading a class for expectant mothers.
Which of the following comments would indicate to the nurse that a pregnant woman understands the recommended dietary caloric increase for pregnancy?
- A. I will need to double my calorie intake since I am now eating for two of us.'
- B. I can add an additional 500 calories by drinking milkshakes.'
- C. I need to add 300 calories by increasing my intake of the four basic food groups.'
- D. I really need to watch my calorie intake so I will not gain too much weight.'
Correct Answer: C
Rationale: Strategy: Determine the outcome of each answer choice. Is it desired? (1) common misconception (2) 500 calories is too many calories, and a milkshake is not a good food source because of its fat content (3) correct-recommended to increase calorie intake by 300 for fetal growth, maternal tissues, and the placenta (4) unsafe for the pregnant client