Nokea
You are caring for a hypertensive client with a new order for captopril (Capoten). Which information should the nurse include in client teaching?
- A. Avoid green leafy vegetables
- B. Restrict fluids to 1000 cc/day
- C. Avoid the use of salt substitutes
- D. Take the medication with meals
Correct Answer: C
Rationale: Avoid the use of salt substitutes. Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based.
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Penicillin V potassium (Pen-Vee-K) 500 mg PO qid is ordered for an adult client. He reports that he took penicillin for the first time two months ago. What should the nurse do?
- A. Be sure that skin testing for a penicillin allergy has been done
- B. Observe for signs of an allergic response
- C. Withhold the penicillin
- D. Notify the physician
Correct Answer: B
Rationale: The client does not have a history of allergic response to penicillin, so there is no need to skin test or withhold the medication. However, allergic responses often occur after the first administration.
A woman who is taking cortisone for an acute exacerbation of rheumatoid arthritis is upset about the fat face she has developed. She says to the nurse, 'I'm going to quit taking that cortisone.' The nurse's response should be based on which understanding?
- A. Cortisone does not cause a fat face.
- B. The symptoms will lessen as her body adjusts to the medication.
- C. The drug should be immediately discontinued when adverse effects occur.
- D. Cortisone should never be abruptly discontinued.
Correct Answer: D
Rationale: Abrupt discontinuation of cortisone can cause adrenal insufficiency; tapering is required to prevent complications.
A client with bi-polar disorder is taking lithium (Lithane). What should the nurse emphasize when teaching about this medication?
- A. Take the medication before meals
- B. Maintain adequate daily salt intake
- C. Reduce fluid intake to minimize diuresis
- D. Use antacids to prevent heartburn
Correct Answer: B
Rationale: Maintain adequate daily salt intake. Salt intake affects fluid volume, which can affect lithium (Lithane) levels; therefore, maintaining adequate salt intake is advised.
A nurse is assigned to perform well-child assessments at a day care center. A staff member interrupts the examinations to ask for assistance. They find a crying 3 year-old child on the floor with mouth wide open and gums bleeding. Two unlabeled open bottles lie nearby. The nurse's first action should be
- A. call the poison control center, then 911
- B. administer syrup of Ipecac to induce vomiting
- C. give the child milk to coat her stomach
- D. ask the staff about the contents of the bottles
Correct Answer: D
Rationale: ask the staff about the contents of the bottles. The nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called.
An 80 year-old client is admitted with a diagnosis of malnutrition. In addition to physical assessments, which of the following lab tests should be closely monitored?
- A. Urine protein
- B. Urine creatinine
- C. Serum calcium
- D. Serum albumin
Correct Answer: D
Rationale: Serum albumin. Serum albumin is a valuable indicator of protein deficiency and, later, nutritional status in adults. A normal reading for an elder's serum albumin is between 3.0-5.0 g/dl.