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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: Failed to generate a rationale of 500+ characters after 5 retries.
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The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?
- A. The treatment requires reapplication in 8 to 10 days.
- B. Bedding and clothing can be boiled or steamed.
- C. Children are not to share hats, scarves, and combs.
- D. Nit combs are necessary to comb out nits.
Correct Answer: C
Rationale: The most crucial information to prevent the spread of lice in schools is to avoid sharing hats, scarves, and combs. This is important as lice can easily spread through shared personal items. Choices A, B, and D are not as critical as choice C in preventing the spread of lice. Reapplication of treatment, boiling or steaming bedding and clothing, and using nit combs are important but not as crucial as avoiding the sharing of personal items.
An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?
- A. Assess the severity and location of the pain
- B. Obtain an order for an analgesic
- C. Reassure the client that this is not unusual for his age
- D. Encourage the client to increase activity
Correct Answer: A
Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.
A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?
- A. Magnesium
- B. Calcium
- C. Chloride
- D. Potassium
Correct Answer: C
Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?
- A. Nausea and vomiting
- B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. Diffuse macular rash
- D. Muscle tenderness
Correct Answer: B
Rationale: A high fever, such as 103 degrees Fahrenheit (39.5 degrees Celsius), in a client with infective endocarditis indicates that the infection may not be responding to the antibiotics and requires immediate medical evaluation. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically associated with the ineffectiveness of antibiotic therapy in infective endocarditis.
A nurse is reinforcing teaching with a client who has a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Eggs
- B. Grapes
- C. Pasta
- D. Dried fruits
Correct Answer: A
Rationale: The correct answer is A: Eggs. Eggs are a good protein source and are less likely to cause blockage or odor issues in clients with colostomies. Grapes, pasta, and dried fruits can be problematic for individuals with colostomies as they may cause digestive issues, blockages, or increased gas production. Grapes have skins that are hard to digest, pasta can cause constipation or blockage, and dried fruits are high in fiber which can lead to blockages.