Question 1: A client with a history of seizures is prescribed phenytoin. Which instruction is most important for the nurse to provide?
Rationale: Phenytoin can cause gingival hyperplasia, so oral hygiene is essential to prevent complications.
Question 2: A nurse is caring for a client who just underwent a lumbar puncture. What is the priority post-procedure action?
Rationale: Keeping the client flat helps prevent cerebrospinal fluid (CSF) leakage, which can cause a post-lumbar puncture headache.
Question 3: A client with newly diagnosed type 1 diabetes asks why insulin injections are necessary. What is the best response?
Rationale: Type 1 diabetes occurs because the pancreas does not produce insulin, requiring replacement therapy with injections.
Question 4: Which intervention should the nurse implement for a client with a chest tube who reports sudden difficulty breathing?
Rationale: Assessing the chest tube for disconnection or blockage is the priority to ensure the system is functioning correctly and preventing complications like pneumothorax.
Question 5: A nurse is providing discharge teaching to a client with heart failure. Which statement indicates the client understands the instructions?
Rationale: Daily weights help monitor fluid retention, and a gain of 2 pounds or more should be reported to the healthcare provider.
