Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has a new prescription for colesevelam powder for oral suspension. The nurse should include which of the following instructions?
A. "Take the medication on an empty stomach.”.
Taking colesevelam on an empty stomach is not necessary. This medication can be taken with food to reduce gastrointestinal side effects.
B. "Increase fiber in your diet.”.
Increasing fiber in the diet is generally beneficial for bowel health, but it is not specific to the use of colesevelam powder for oral suspension.
C. "Discard the oral suspension if it is cloudy after mixing.”.
This is the correct answer because if the oral suspension of colesevelam is cloudy after mixing, it indicates that the medication may have degraded or is not suitable for consumption. Discarding the cloudy suspension ensures that the client receives the appropriate dose and effectiveness of the medication.
D. "Avoid drinking grapefruit juice.".
Avoiding grapefruit juice is important for some medications, but it is not relevant to colesevelam. Grapefruit juice can interfere with the metabolism of certain drugs, but it does not have a significant effect on colesevelam.
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Full Explanation
Choice A rationale:
Taking colesevelam on an empty stomach is not necessary. This medication can be taken with food to reduce gastrointestinal side effects.
Choice B rationale:
Increasing fiber in the diet is generally beneficial for bowel health, but it is not specific to the use of colesevelam powder for oral suspension.
Choice C rationale:
This is the correct answer because if the oral suspension of colesevelam is cloudy after mixing, it indicates that the medication may have degraded or is not suitable for consumption. Discarding the cloudy suspension ensures that the client receives the appropriate dose and effectiveness of the medication.
Choice D rationale:
Avoiding grapefruit juice is important for some medications, but it is not relevant to colesevelam. Grapefruit juice can interfere with the metabolism of certain drugs, but it does not have a significant effect on colesevelam.
Similar Questions
A nurse is reviewing the prescriptions for a client who has a new diagnosis of bacterial meningitis. Which of the following prescriptions should the nurse clarify with the provider?
A. Place the client on droplet precautions.
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
B. Perform a cranial nerve assessment on the client every 2 hr.
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
C. Assist the client out of bed three times per day.
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
D. Assess the client's weight daily.
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.
Full Explanation
Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan of care?
A. Assess the need for oral suction every 4 hr.
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
B. Check the ventilator settings every 12 hr.
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
C. Keep the head of the client's bed elevated at 30°.
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
D. Perform oral hygiene using an alcohol-based oral rinse.
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.
Full Explanation
Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.
A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?
A. Poor skin turgor.
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
B. Fruity breath odor.
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
C. Kussmaul respirations.
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
D. Irritability.
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.
Full Explanation
Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.