The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate.
The nurse implements the prescription with which understanding about why acetaminophen is prescribed?

Fever usually accompanies myocardial infarction.

Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.

Headache is a common side effect of nitrates.

Acetaminophen potentiates the therapeutic effect of nitrates.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Fever usually accompanies myocardial infarction. This statement is incorrect. While fever can occur with myocardial infarction, it is not a common or primary symptom. Acetaminophen is not prescribed for this reason.

Choice B rationale

Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does. This statement is correct but not the reason for prescribing acetaminophen before nitrates. Acetaminophen is chosen for its analgesic properties without affecting platelet function.

Choice C rationale

Headache is a common side effect of nitrates. This statement is correct. Nitrates can cause vasodilation, leading to headaches. Acetaminophen is prescribed to manage this common side effect.

Choice D rationale

Acetaminophen potentiates the therapeutic effect of nitrates. This statement is incorrect. Acetaminophen does not enhance the therapeutic effects of nitrates; it is used to manage side effects like headaches.

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Correct Answer is C

Explanation

Choice A rationale

Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.

Choice B rationale

Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.

Choice C rationale

A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.

Choice D rationale

A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.

A. Maintain the client in a supine position. B. Maintain a high-Fowler’s position when the client is in bed. C. Elevate the stump on a pillow. D. Position the client on the abdomen for 20 to 30 minutes twice a day.

Correct Answer is D

Explanation

Choice D rationale

Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.

Choice A rationale

Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.

Choice B rationale

Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.

Choice C rationale

Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

Correct Answer is C

Explanation

The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?

Correct Answer is D

Explanation

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?

The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?

A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?