Before administering a laxative to a bedfast client, it is most important for the nurse to perform what
assessment?
a-Observe the skin integrity of the
... [Show More] client's rectal and sacral areas
b-assess the client strength in moving and turning in the bed
c-evaluate the client's ability to recognize the urge to defecate
d-determine the frequency and consistency of bowel movements Correct Answer- D
rationale
the nurse should ensure that the client is not experiencing diarrhea (answer choice D) before
administering a laxative, which will increase the frequency of bowel movements. answer choices A,B,C
R4 and assessments for the provision of care when the client experience is a valve, but are of less
priority then answer choice D which provides data about the possible need to hold medication
A female client with multiple sclerosis reports having less fatigue and improved memory since she began
using the herbal supplement, ginkgo biloba. Which information is most important for the nurse to
include in the teaching plans for this client?
a-Aspirin and nonsteroidal anti-inflammatory drugs interact with ginkgo
b-nausea and diarrhea can occur when using this supplement
c-anxiety and headaches increased with use of ginkgo
d-ginkgo biloba use should be limited and not taken during pregnancy Correct Answer- Rationale
ginkgo biloba has blood thinning properties and should not be used in taking aspirin or unsafe which
increased the risk for bleeding. nausea diarrhea anxiety and headaches are also side effects of
supplements but they do not pose the same risk as a. Although D is accurate A has a higher priority
In explaining the benefits of the combination anti-infective drug code tri-moxazole/TMP-SMZ (bactrium)
to a client receiving the medication for a urinary tract infection, more rationale to the nurse provide?
-Each drug could cause damage to the kidneys if taken separately-one drug reduces the risk of side effects caused by the drug
-while one drug provide releif, the other fights the infection
-the two drugs work together to reduce resistance of the bacterial infection of symptoms Correct
Answer- D
rationale
the combination of drugs and bacteria work synergistically to reduce bacterial resistance enterprise D,
thereby increasing the drug therapeutic benefits answer choices a B &C are incorrect rationales
Client being treated with Haldol for schizophrenia is complaining of jaw tightness & a stiff neck. Which
interventions should the nurse impliment?
-give PRN those of diphenhydramine Benadryl
-assess client other sensory hallucinations
-massage neck until muscles begin to relax
-obtain a 12 lead EKG Correct Answer- Rationale
jaw tightness and a stiff neck are signs of tardive dyskinesia, a serious side effect of health all that can be
reversed with Benadryl answer choice A. the client complaints are not considered hallucinations b.
Massaging the neck does not eliminate the symptoms. A 12 lead EKG is not indicated because the pain is
not cardiac in origin.
Which intervention is most important for the nurse implement for a client is receiving lispro Humalog
insulin?
-Check blood glucose levels every six hours
-provide meals at the same time that insulin is given
-assess for hypoglycemia between meals
-keeping oral liquid or glucose source available Correct Answer- B
Rationale
Humalog is a rapid acting insulin 15 minutes, so meals should be readily available time administration of
lispro (B). Although glucose blood levels a, monitoring for hypoglycemia see, and keeping emergency
source of glucose available B should be implemented for client receiving any form of insulin those who
take these are at greatest risk for rapid hypoglycemia shortly after it is administered
Client takes nonsteroidal anti-inflammatory drugs every day for rheumatoid arthritis is being treated for
anemia which intervention is most important for the nurse to include any plan of careobserve for gastrointestinal bleeding
monitor liver function test results
protect skin from bruising
offered dietary selections rich in iron
rationale Correct Answer- rationale
the client is at risk for gastrointestinal bleeding duty history of NSAID a .new onset anemia indicates
bleeding may be present. NSAIDS May impact liver function b, but this is of less immediacy than a. C is a
basic core measure but not one of high priority for this client. D often useful for persons with anemia
but is of less priority than a [Show Less]