Nokea
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.'
- B. You will have to take this medication for about a year.'
- C. The medication must be continued so the fluid problem is controlled.'
- D. Please talk to your health care provider about medications and treatments.'
Correct Answer: C
Rationale: The medication must be continued so the fluid problem is controlled.' This is the most therapeutic response and gives the client accurate information.
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Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
- A. Sedative hypnotics are effective analgesics
- B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
- C. Caffeine beverages can increase the effect of sedative hypnotics
- D. Avoidance of excessive exercise and high temperature is recommended
Correct Answer: B
Rationale: Sudden cessation of any medication, unless medically necessary, is ill-advised.
The provider order reads 'Aspirate nasogastric (NG) feeding tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?
- A. Hold the tube feeding and notify the provider
- B. Administer the tube feeding as scheduled
- C. Irrigate the tube with diet cola soda
- D. Apply intermittent suction to the feeding tube
Correct Answer: A
Rationale: Hold the tube feeding and notify the provider. A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal placement.
The nurse sees multiple items on the client's bedside table. Which items should the nurse remove because they pose a risk of infection for the client? Select all that apply.
- A. The menu from the client's last meal
- B. A glass of water without a cover
- C. An empty urinal that had been rinsed
- D. A sealed package of soda crackers
- E. A pitcher of water covered with a lid
- F. A bloody alcohol swab from an injection
Correct Answer: B,C,F
Rationale: B: Uncovered water can become contaminated over time. C: A rinsed urinal may still harbor microorganisms. F: A bloody swab is a biohazard and can transmit pathogens. A, D, E are safe as they are either non-contaminable or properly sealed.
A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?
- A. What are you taking for pain and does it provide total relief?'
- B. Did your provider recommend that you be tested for Chlamydia?'
- C. Do you have any questions about your care?'
- D. Did you know a consequence of epididymitis is infertility?'
Correct Answer: B
Rationale: Did your provider recommend that you be tested for Chlamydia?' Epididymitis can result from Chlamydia infection, in which case the client's sexual partners should be tested as well. All of the questions should be asked, however, determining the reason for the client's referral is the most important to start with.
As part of an infection-control policy, newly admitted clients are screened for possible undiagnosed or unsuspected infectious tuberculosis. Which questions should the nurse ask to accomplish this screening? Select all that apply.
- A. "Have you been exposed to someone with tuberculosis?"
- B. "What was the date of your last tuberculin skin test?"
- C. "Have you had a cough that lasted more than 3 weeks?"
- D. "Have you experienced blood in your urine or stools?"
- E. "Have you had a recent weight gain, fever, or night sweats?"
Correct Answer: A,B,C
Rationale: A: Exposure history is key for TB screening. B: Recent skin tests indicate prior screening. C: Prolonged cough is a TB symptom. D: Blood in urine/stools is unrelated. E: Weight loss, not gain, is associated with TB.