A nurse is caring for a client who has a new prescription for nitroglycerin. The
nurse should monitor for which of the following adverse effects of the
medication?
Nocturia
Increased saliva
production Flushing
Fever
Flushi
ng
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start
sipping out and causing flushing
A nurse is preparing to obtain a postprandial blood glucose level from a
client who has diabetes mellitus. Which of the following actions should the
nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position.
D. Hold the client's finger in a
dependent position.
Rationale:
,The nurse should clean the client's finger with an alcohol swab and prick
the side of the finger, not the central tip, to obtain a postprandial blood
glucose level.
The nurse should not apply the first drop of blood to the test strip since the
alcohol could cause false reading.
Hexachlorophene is not recommended for cleaning the client's finger as
it can cause tissue damage.
A nurse is reinforcing teaching with a client about breast self-
examinations. Which of the following statements by the client indicates
an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month."
A. "It is common for one breast to be
larger than the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than
the right.
This is because of the difference in the percentage of breast tissues and fatty
tissues, that's why they react differently to hormonal changes.
,"Dimpling on the skin on breasts is NOT common" Physician
consultation should be taken regarding this as it can be a sign of breast
cancer.
"Self-breast exams are recommended to be performed after a week when the
period starts." The rest of the month breasts reamain tender due to hormone
fluctuation.
, "Self-Breast exams should be performed every month." For women in
reproductive age usually after a week when the period starts and at the same
day of every month for women who have attained menopause.
A nurse is reinforcing teaching with a client who has a new ileostomy.
Which of the following statements by the client indicates an understanding
of the teaching?
a) "I will need to empty the bag every 4 to 6 hours."
b) "I will use moisturizing soap to
clean around the stoma before
applying the bag."
c) "I will use a skin sealant before I apply the bag."
d) "I will cut the wafer opening one-
fourth of an inch larger than the
stoma."
C. "I will use a skin sealant before I
apply the bag."
Rationale:
An ileostomy is an opening in the belly that's made during surgery to allow
waste to pass out of the body. It requires special care to keep the skin around
it clean and prevent infection. A skin sealant can protect the skin from
irritation and help the bag stick better. The other statements are incorrect
because:
a) You may need to empty the bag more often than every 4 to 6 hours,
depending on how much waste you produce.
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