LEARNING SYSTEM PN 3.0
"I have not had a BM today." : The nurse should identify that diphenoxylate-atropine is an opioid
used to treat diarrhea. The therapeutic response of this med is a decrease in the frequency of
watery stools due to reduced motility of the intestinal lining - ANS - A nurse is monitoring a client
who received diphenoxylate-atropine. Which of the following statements by the client should
indicate to the nurse that the medication has been effective?
\"I have noticed my urine is orange in color." - The nurse should identify that an adverse effect of
rifampin can be red-orange colored urine, saliva, sweat n tears. The nurse should also inform
the client that permanent staining of contact lenses can occur. However, this adverse effect is
harmless. The client should inform the provider if urine becomes dark in color since this can be
an indication of hepatoxicity. - ANS - A nurse is caring for a client who has TB and is taking
rifampin. Which of the following statements should indicate to the nurse that the client is
experiencing an adverse effect?
\"I should check my blood glucose levels more often when I am sick.": Blood glucose levels
should be checked every 3 hrs during illness for a client who has Type 1 DM, even if the client
consumes fewer calories that usual. Hyperglycemia often occurs w/ an infection, requiring
additional doses of insulin - ANS - A nurse is reinforcing teaching with a 13 year old client who
has Type 1 DM. Which of the following client statements indicates an understanding of diabetes
mellitus management?
\"I will eat fruits & veggies that have a high potassium content everyday." - Hypokalemia is an
adverse effect of diuretic therapy. Because the client is taking digoxin, the client will need to
maintain a potassium level between 3.5 to 5.0 mg/dL to avoid digoxin toxicity. - ANS - A nurse is
reinforcing discharge teaching with a client who has HF and a prescription for digoxin 0.125 mg
PO daily and furosemide 20 mg PO daily. Which of the following statements by the client
indicates an understanding of the teaching?
\"It must be difficult for you not to know what the doctor will find." - The nurse is expressing
empathy in order to acknowledge the clients feelings and encourage further communication. -
ANS - A nurse is caring for a client who is scheduled for a biopsy of a mass in a testicle. The
client asks, "Do you think the doctor will find cancer?" Which of the following responses should
the nurse make?
\"Restraining the client can increase confusion." : Restraining a confused client can worsen
confusion. The nurse should use other methods to prevent wandering - ANS - A nurse is caring
for a client who is confused and wanders at night. The nurse asks the charge nurse if the client
can be placed in physical restraints at bedtime. Which of the following responses should the
charge nurse provide?
\Administer the medication into the client's abdomen - The heparin should be administered into
the client's abdomen. - ANS - A nurse is administering subcutaneous heparin to a client who is
at risk for DVT. Which of the following actions should the nurse take?
\Alterations in the GI flora : The typical GI flora are often destroyed by broad-spectrum
antibiotics such as amoxicillin, causing poor digestion n possible superinfection with other
bacteria. - ANS - A nurse in a provider's office is collecting data from a client who has been
"I have not had a BM today." : The nurse should identify that diphenoxylate-atropine is an opioid
used to treat diarrhea. The therapeutic response of this med is a decrease in the frequency of
watery stools due to reduced motility of the intestinal lining - ANS - A nurse is monitoring a client
who received diphenoxylate-atropine. Which of the following statements by the client should
indicate to the nurse that the medication has been effective?
\"I have noticed my urine is orange in color." - The nurse should identify that an adverse effect of
rifampin can be red-orange colored urine, saliva, sweat n tears. The nurse should also inform
the client that permanent staining of contact lenses can occur. However, this adverse effect is
harmless. The client should inform the provider if urine becomes dark in color since this can be
an indication of hepatoxicity. - ANS - A nurse is caring for a client who has TB and is taking
rifampin. Which of the following statements should indicate to the nurse that the client is
experiencing an adverse effect?
\"I should check my blood glucose levels more often when I am sick.": Blood glucose levels
should be checked every 3 hrs during illness for a client who has Type 1 DM, even if the client
consumes fewer calories that usual. Hyperglycemia often occurs w/ an infection, requiring
additional doses of insulin - ANS - A nurse is reinforcing teaching with a 13 year old client who
has Type 1 DM. Which of the following client statements indicates an understanding of diabetes
mellitus management?
\"I will eat fruits & veggies that have a high potassium content everyday." - Hypokalemia is an
adverse effect of diuretic therapy. Because the client is taking digoxin, the client will need to
maintain a potassium level between 3.5 to 5.0 mg/dL to avoid digoxin toxicity. - ANS - A nurse is
reinforcing discharge teaching with a client who has HF and a prescription for digoxin 0.125 mg
PO daily and furosemide 20 mg PO daily. Which of the following statements by the client
indicates an understanding of the teaching?
\"It must be difficult for you not to know what the doctor will find." - The nurse is expressing
empathy in order to acknowledge the clients feelings and encourage further communication. -
ANS - A nurse is caring for a client who is scheduled for a biopsy of a mass in a testicle. The
client asks, "Do you think the doctor will find cancer?" Which of the following responses should
the nurse make?
\"Restraining the client can increase confusion." : Restraining a confused client can worsen
confusion. The nurse should use other methods to prevent wandering - ANS - A nurse is caring
for a client who is confused and wanders at night. The nurse asks the charge nurse if the client
can be placed in physical restraints at bedtime. Which of the following responses should the
charge nurse provide?
\Administer the medication into the client's abdomen - The heparin should be administered into
the client's abdomen. - ANS - A nurse is administering subcutaneous heparin to a client who is
at risk for DVT. Which of the following actions should the nurse take?
\Alterations in the GI flora : The typical GI flora are often destroyed by broad-spectrum
antibiotics such as amoxicillin, causing poor digestion n possible superinfection with other
bacteria. - ANS - A nurse in a provider's office is collecting data from a client who has been
