108. A client is being discharged with sublingual nitroglycerin (Nitrostat).

The client should be cautioned by the nurse to

1.
2.
3.
4.

take the medication five minutes after the pain has started.
stop taking the medication if a stinging sensation is absent.
take the medication on an empty stomach.
avoid abrupt changes in posture.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) should be taken immediately when pain is felt
(2) presence or absence of a stinging sensation is not indicative of the effect of the
drug
(3) should be taken when pain is experienced
(4) correctnitroglycerin can cause hypotension; client should avoid changing
positions quickly to decrease the chances of falling
109. The RN is making nursing assignments for the burn unit. Which of the
following indicates the MOST appropriate assignment for a client who has a
positive cytomegalovirus (CMV) titer?
1.
2.
3.
4.

A nurse with an upper respiratory infection.

A young nurse who is eight weeks pregnant.
A male nurse who is CMV-negative.
An older nurse with 30 years experience.

Strategy: Determine the nurse with the least risk.

(1) those with a cytomegalovirus-positive titer are often immunosuppressed clients
who should be protected from other pathogens
(2) CMV is fetotoxic, should inform client of risks
(3) this nurse is at increased risk for developing the disease
(4) correctmost appropriate option due to decreased risk
110. A 13-year-old male with muscular dystrophy (MD) has just developed
nocturia. The client wants to know about external catheters. The nurse
should base the response on which of the following statements?
1.
2.
3.
4.

The catheter can be removed during the day.

External catheters are uncomfortable.
The catheter would drain into a bag at the bedside or on the wheelchair.
The external condom catheter is easy to apply.

Strategy: Think about each answer choice.

(1) correctbeing free from any drain bags during the day would appeal to a 13year-old
(2) is negative
(3) would be embarrassing to a 13-year-old
(4) it would be impossible for a teen with muscular weakness to put on an external
catheter