The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?
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Solution
Prinzmetal’s angina
If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms.
Options A, C, and D: There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches.
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:
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Solution
Tuberculosis
A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis.
Option A: If the answer had said pneumocystis pneumonia, it would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem.
Options B and D: They are not directly related to the stem.
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
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Solution
Check the client for bladder distention
If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary.
Options B, C, and D: These are actions that relate to postpartum hemorrhage.
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
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Solution
Call security for assistance and prepare to sedate the client.
If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him.
Option B: Telling the client to calm down will not work.
Option C: Telling the client that if he continues he will be punished is a threat and may further anger him.
Option D: If the client is left alone he might harm himself.
The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
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Solution
30 minutes before meals.
Proton pump inhibitors reduce the production of acid in the stomach. Proton pump inhibitors work best when they are taken 30 minutes before the first meal of the day.
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
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Solution
HibTITER
The Haemophilus influenza vaccine is given at 4 months with the polio vaccine.
Options B, C, and D: Mumps, Hepatitis B, and MMR vaccines are given later in life.
A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
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Solution
Reverse drug toxicity and prevent tissue damage
Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative.
Options A, B, and C: Leucovorin does not treat iron deficiency, increased neutrophils, or have a synergistic effect.
The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:
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Solution
The umbilical cord needs time to separate.
The umbilical cord needs time to dry and fall off before putting the infant in the tub.
Options A, C, and D: Although these statements might be important, they are not the primary answer to the question.
The physician has prescribed Novolog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
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Solution
“I will make sure I eat breakfast within 10 minutes of taking my insulin.”
NovoLog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin.
Option B does not address a particular type of insulin, so it is incorrect.
Option C: NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m.
Option D: There is no need to save the dessert until bedtime.
The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
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Solution
Split pea soup, mashed potatoes, pudding, milk
The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing.
Options A, C, and D: The following food items would require more chewing and, thus, are incorrect.