A nurse is preparing to administer nortriptyline 150 mg PO for a client who has depression. Available is chlorpromazine hydrochloride 75 mg tablets. How many tablets should the nurse administer with each dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer and Explanation

The Correct Answer is ["2"]

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Correct Answer is A

Explanation

A. This is a crucial step to prevent aspiration (the inhalation of oral contents into the lungs). Turning the client on their side helps to facilitate drainage and prevents oral fluids and debris from entering the airway during oral care.
B. Using a stiff toothbrush can be harmful to the gums and oral tissues, especially for clients who are unresponsive and may not be able to indicate discomfort. A soft-bristled toothbrush or moistened gauze is recommended for cleaning the teeth and gums to prevent injury and maintain oral hygiene effectively.
C. Applying petroleum jelly or a similar barrier ointment helps to moisturize and protect the lips from dryness and cracking, which can be common in clients who are unresponsive and may not be able to moisten their lips independently.
D. Using the thumb and index finger to keep the client's mouth open is gentle and effective. This technique allows the nurse to visualize and clean the oral cavity adequately without causing discomfort or injury to the client.

A. Reposition the client at least every 2 hr. B. Keep the head of the bed elevated. C. Keep the client's skin moist. D. Massage the client's bony prominences.

Correct Answer is A

Explanation

A. Repositioning the client regularly is a critical measure to prevent pressure ulcers. This helps relieve pressure on vulnerable areas of the body and improves circulation. Turning the client every 2 hours is a common guideline to prevent prolonged pressure on any one area.
B. Keeping the head of the bed elevated continuously is not recommended as it can increase shear and friction, leading to skin breakdown.
C. Keeping the client's skin moisturized is important for maintaining skin integrity, but excessive moisture can increase the risk of skin breakdown, especially in areas susceptible to pressure ulcers. The nurse should aim to keep the skin clean, dry, and free from excessive moisture to prevent maceration.
D. Massaging bony prominences is not recommended as a preventive measure for pressure ulcers. In fact, massaging these areas can increase the risk of tissue damage due to friction and shearing forces. The focus should be on relieving pressure through proper positioning and support surfaces rather than massage.

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

A nurse is preparing to administer dextrose 5% in water (DSW) 100 mL to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse. "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect?

A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?

A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?