Nokea
Which statement made by the client indicates an understanding of the instructions regarding the administration of alendronate (Fosamax)?
- A. I will take the medication at bedtime to avoid stomach upset.
- B. I will take the medication with a full glass of water first thing in the morning.
- C. I will lie down for 30 minutes after taking the medication.
- D. I will take the medication with food to reduce stomach irritation.
Correct Answer: B
Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.
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A client with chronic obstructive pulmonary disease (COPD) is experiencing difficulty breathing. What is the nurse's priority intervention?
- A. Administer a bronchodilator via nebulizer.
- B. Increase the client's oxygen flow rate.
- C. Elevate the head of the bed.
- D. Reposition the client to a side-lying position.
Correct Answer: B
Rationale: In clients with COPD experiencing difficulty breathing, increasing the client's oxygen flow rate is the priority intervention. This action helps to improve oxygenation and relieve shortness of breath. While bronchodilators and other medications may be necessary, providing immediate oxygen support is crucial. Elevating the head of the bed and repositioning the client can assist with breathing comfort but do not address the immediate need for improved oxygenation in COPD exacerbation.
A client receiving radiation therapy for breast cancer reports dry, peeling skin at the treatment site. What action should the nurse recommend?
- A. Apply lotion to the treatment area.
- B. Use mild soap and water to cleanse the area.
- C. Cover the area with a sterile dressing.
- D. Allow the skin to air dry after washing.
Correct Answer: B
Rationale: The correct recommendation for a client with dry, peeling skin at a radiation therapy treatment site is to use mild soap and water to cleanse the area. This approach helps in preventing skin irritation and reduces the risk of infection. Applying lotion (Choice A) may further irritate the skin due to the chemicals present in the lotion. Covering the area with a sterile dressing (Choice C) is not necessary unless there is an open wound that needs protection. Allowing the skin to air dry after washing (Choice D) may lead to further dryness and peeling.
A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?
- A. Limit sodium intake to 2 grams per day.
- B. Choose fresh fruits and vegetables.
- C. Drink at least 8 glasses of water daily.
- D. Avoid processed foods and canned soups.
Correct Answer: D
Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.
The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to
- A. Limit the effects of tissue damage
- B. Relieve pain and anxiety
- C. Prevent arrhythmias
- D. Reduce anxiety
Correct Answer: A
Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.
The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?
- A. Encourage the client to ambulate
- B. Apply a warm compress to the left leg
- C. Elevate the client's left leg
- D. Administer a prescribed anticoagulant
Correct Answer: C
Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.