A nurse is teaching a client who is taking medication before bedtime. The nurse should include the following instructions:

Do not take the medication before bedtime.

Take the medication with a full glass of water.

This medication must be taken on an empty stomach.

Expect abdominal pain with this medication.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

“Do not take the medication before bedtime” is incorrect because the timing of medication administration depends on the specific medication and its intended effects. Some medications are specifically prescribed to be taken at bedtime to help with sleep or to reduce side effects that might occur during the day.

Choice B Reason:

“Take the medication with a full glass of water” is correct because many medications require adequate hydration to ensure proper absorption and to prevent irritation of the esophagus and stomach. Taking medication with a full glass of water helps to ensure that the medication reaches the stomach quickly and reduces the risk of esophageal irritation or damage.

Choice C Reason:

“This medication must be taken on an empty stomach” is incorrect unless the specific medication requires it. Some medications are better absorbed on an empty stomach, but this is not a universal rule and depends on the medication’s formulation and intended use.

Choice D Reason:

“Expect abdominal pain with this medication” is incorrect because not all medications cause abdominal pain. If a medication is known to cause abdominal pain, the nurse should provide additional instructions on how to manage this side effect or discuss alternative medications with the healthcare provider.

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Correct Answer is A

Explanation

Choice A reason: Applying compression stockings is a key prophylactic intervention to prevent complications of immobility, such as deep vein thrombosis (DVT) and venous thromboembolism (VTE). Compression stockings help improve blood circulation in the legs by applying graduated pressure, which reduces the risk of blood clots forming in the deep veins. This is particularly important for immobile patients who are at higher risk of developing DVT due to prolonged periods of inactivity.

Choice B reason: Raising all side rails is primarily a safety measure to prevent falls and does not directly address the complications of immobility. While it is important for patient safety, it does not have a significant impact on preventing issues like DVT, pressure ulcers, or muscle atrophy. Therefore, it is not considered a prophylactic intervention for immobility-related complications.

Choice C reason: Inserting a urinary catheter is not a prophylactic intervention for preventing complications of immobility. Catheters are used to manage urinary retention or incontinence but can increase the risk of urinary tract infections (UTIs) if not managed properly. They do not address the primary complications associated with immobility, such as DVT or pressure ulcers.

Choice D reason: Using friction-reducing devices is important for preventing pressure ulcers and skin injuries in immobile patients. These devices help minimize friction and shear forces on the skin, which can lead to pressure ulcers. While this is a valuable intervention, it is not as comprehensive as compression stockings in preventing a range of immobility-related complications.

A. Asthma B. Hypertension C. Glaucoma D. Depression

Correct Answer is C

Explanation

Choice A reason: Asthma

Diphenhydramine is an antihistamine that can cause drying of the airways and thickening of bronchial secretions, which might exacerbate asthma symptoms. However, it is not strictly contraindicated in asthma patients. Instead, caution is advised, and it should be used under medical supervision if necessary.

Choice B reason: Hypertension

While diphenhydramine can cause mild increases in blood pressure due to its anticholinergic effects, it is not contraindicated in patients with hypertension. Patients with hypertension should use it cautiously and under medical advice, but it is not an absolute contraindication.

Choice C reason: Glaucoma

Diphenhydramine is contraindicated in patients with glaucoma, particularly closed-angle glaucoma. This is because diphenhydramine has anticholinergic properties that can increase intraocular pressure, potentially worsening the condition. Patients with glaucoma should avoid using diphenhydramine to prevent complications related to increased eye pressure.

Choice D reason: Depression

Diphenhydramine is not contraindicated in patients with depression. However, it can cause drowsiness and sedation, which might affect mood and energy levels. Patients with depression should use it cautiously and under medical supervision, but it is not an absolute contraindication.

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A nurse is teaching a client who is taking medication before bedtime. The nurse should include the following instructions:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

Correct Answer is A

Explanation

A client asks the nurse about a prescription for the antihistamine, diphenhydramine (Benadryl). The nurse should teach the client that this medication is contraindicated in clients who have a history of which condition?

Correct Answer is C

Explanation

A nurse is assessing a client who is 2 days postoperative and is auscultating their bilateral breath sounds. The nurse notes absent breath sounds in the bases. The nurse should suspect which postoperative complication is occurring in this client?

A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?

A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?

A nurse on the medical-surgical unit is conducting a fall risk assessment on four clients. Which of these clients would be at greatest risk for falls?

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?

A nurse is providing teaching to a postoperative client regarding diet. Which nutrient is responsible for maintaining healthy bowel elimination?