While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining the client’s medication history, the nurse should determine if the client keeps which medication on hand?

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Question 1 of 9

While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining the client’s medication history, the nurse should determine if the client keeps which medication on hand?

Correct Answer: A

Rationale: Rationale: A: Diphenhydramine hydrochloride (Benadryl) is an antihistamine commonly used to treat allergic reactions, including those from bee stings. It can help alleviate symptoms like itching and swelling. Keeping Benadryl on hand is crucial for managing an allergic reaction promptly. Other Choices: B: Guaifenesin (Robitussin) is an expectorant used to treat coughs, not allergic reactions. C: Pseudoephedrine hydrochloride (Sudafed) is a decongestant used for nasal congestion, not allergic reactions. D: Loperamide (Imodium) is an antidiarrheal used to treat diarrhea, not allergic reactions.

Question 2 of 9

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.

Question 3 of 9

A nurse approaches a hospitalized poststroke patient from the patient’s left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse’s presence or voice. Which action should the nurse take first?

Correct Answer: A

Rationale: Rationale: 1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit. 2. This step helps determine if the lack of response is due to a sensory issue. 3. It allows the nurse to rule out unilateral neglect or hemianopsia. 4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients. Other Choices: B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing. C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits. D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.

Question 4 of 9

Before a cancer receiving total parenteral nutrition (TPN) resumes a normal diet, the nurse teaches him about dietary sources of minerals. Which foods are good sources of zinc?

Correct Answer: D

Rationale: The correct answer is D: Whole grains and meats. Zinc is found in high amounts in these foods. Meats, especially red meats and seafood, are rich sources of zinc. Whole grains like wheat, rice, and oats also contain significant amounts of zinc. Other choices are incorrect because fruits and vegetables are not typically good sources of zinc. Yeast and legumes are good sources of other minerals but not specifically zinc. It is important for the cancer patient to consume zinc-rich foods to support their immune system and overall health during recovery.

Question 5 of 9

The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

Correct Answer: A

Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection. Summary of why other choices are incorrect: B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection. C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections. D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.

Question 6 of 9

The nurse administers chemotherapeutic drugs to a client with cancer. What adverse effects are most common?

Correct Answer: B

Rationale: The correct answer is B: Nausea and vomiting. Chemotherapeutic drugs commonly cause nausea and vomiting due to their effect on the gastrointestinal system. This is because these drugs can irritate the stomach lining and trigger the vomiting center in the brain. Nausea and vomiting are well-documented side effects of chemotherapy and are often managed with antiemetic medications. A: Painful mouth sores are a common side effect of some chemotherapeutic drugs, but they are not the most common adverse effect. C: Frequent diarrhea can occur as a side effect of chemotherapy, but it is less common than nausea and vomiting. D: Constipation is not a common adverse effect of chemotherapeutic drugs; in fact, diarrhea is more commonly seen.

Question 7 of 9

The nurse recognizes that the major early problem for Mr. Gabatan will be:

Correct Answer: A

Rationale: The correct answer is A: Bladder control. This is the major early problem for Mr. Gabatan because urinary retention is a common complication post-surgery, especially for older males like him. Bladder control is essential for preventing urinary tract infections and maintaining overall health. Quadriceps setting (B) and client education (C) are important but not as critical early on. Use of aids for ambulation (D) is important but not the major early problem compared to bladder control in this case.

Question 8 of 9

A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In hemodialysis, potassium levels can be elevated due to impaired renal excretion. High potassium can lead to muscle weakness and numbness. The client's K level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), confirming hyperkalemia. Na, Cl, and Ca levels are within normal limits, ruling out hypernatremia, hypochloremia, and hypocalcemia as the client's primary electrolyte imbalance. Monitoring and managing hyperkalemia are crucial to prevent life-threatening complications like cardiac arrhythmias.

Question 9 of 9

Which of the following would be the most appropriate nursing intervention when caring for a client with a fractured rib?

Correct Answer: A

Rationale: Correct Answer: A - Apply immobilization device after examination by physician Rationale: 1. Immobilization helps reduce pain and prevent further injury. 2. Physician examination ensures proper diagnosis and treatment plan. 3. Immobilization device may include chest binders or splints for support. 4. It is crucial to follow medical advice to prevent complications. Summary: B: Discouraging deep breaths can lead to respiratory complications. C: Advising against analgesics can increase pain and hinder recovery. D: Increased fluid intake is important but not directly related to rib fracture care.

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