Nokea
Which nursing action is most appropriate when applying a new transdermal patient?
- A. Rotate the application site.
- B. Clean the skin with alcohol.
- C. Tape the patch to the client's chest.
- D. Take the blood pressure afterward.
Correct Answer: A
Rationale: Rotating the application site for a nitroglycerin patch prevents skin irritation and ensures consistent drug absorption.
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To provide adequate care for the client with worsening left-sided heart failure, the intensive care unit (ICU) nurse should be a full of the following on a daily basis?
- A. Pupil response
- B. Peripheral edema
- C. Appetite
- D. Weight
Correct Answer: B,D
Rationale: Peripheral edema and weight are key indicators of fluid status in heart failure.
The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching?
- A. I must take all the prescribed antibiotics.'
- B. I may get a vaginal yeast infection with penicillin.'
- C. I will have no problems as long as I take my medication.'
- D. My throat culture was positive for a streptococcal infection.'
Correct Answer: C
Rationale: Assuming no problems with medication (C) ignores potential complications like recurrence, indicating a need for teaching. Completing antibiotics (A), yeast infection (B), and strep culture (D) are correct.
The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biological tissue valve replacement?
- A. The client must take lifetime anticoagulant therapy.
- B. The client’s infections are easier to treat.
- C. There is a low incidence of thromboembolism.
- D. The valve has to be replaced frequently.
Correct Answer: D
Rationale: Biological valves (D) have limited durability, often requiring replacement. Anticoagulation (A) is for mechanical valves, infections (B) are not easier, and thromboembolism (C) is lower but not a disadvantage.
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.
An adult is diagnosed with hypertension. He is prescribed chlorothiazide (Diuril) 500 mg PO. What nursing instruction is essential for him?
- A. Drink at least two quarts of liquid daily.
- B. Avoid hard cheeses.
- C. Drink orange juice or eat a banana daily.
- D. Do not take aspirin.
Correct Answer: C
Rationale: Chlorothiazide, a diuretic, can cause potassium loss. Consuming potassium-rich foods like orange juice or bananas helps prevent hypokalemia.