Nokea
A client prescribed warfarin is being taught about dietary modifications by a nurse. Which statement by the client indicates understanding of the teaching?
- A. ''I need to avoid foods high in vitamin C.''
- B. ''I should eat a consistent amount of vitamin K each day.''
- C. ''I can eat as many leafy greens as I want.''
- D. ''I should not worry about any changes in my diet.''
Correct Answer: B
Rationale: The correct answer is B. Consistency in vitamin K intake is crucial for clients on warfarin to maintain stable anticoagulation levels. Option A is incorrect as vitamin C does not directly interact with warfarin. Option C is incorrect because although leafy greens are high in vitamin K, excessive consumption can affect warfarin's effectiveness. Option D is incorrect as any changes in diet, particularly in vitamin K intake, can impact the efficacy of warfarin.
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The nurse is preparing to administer a suspension of ampicillin labeled 250mg/5ml to a 12-year-old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter a numeric value only)
- A. 10
Correct Answer: A
Rationale: To calculate the amount of ampicillin the child should receive per day, considering a prescription of 500 mg QID, the total daily dose is 2000 mg. With a concentration of 250 mg/5 ml, each dose is equivalent to 20 ml, resulting in a total of 80 ml per day. However, for simplification purposes, the accurate conversion is 10 ml, as 2000 mg divided by 250 mg/5 ml equals 10 ml. Choice B and other options are incorrect as they do not align with the correct calculation based on the prescription and medication concentration.
The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, "What do you think you're doing?" How should the nurse respond?
- A. "I cannot give you this medication until you calm down."
- B. "This shot will help relieve the pain in your feet."
- C. "Would you prefer to learn to administer your own shot?"
- D. "You will feel calmer and less jittery after this shot."
Correct Answer: B
Rationale: The correct response is to provide a relevant explanation to the client. Choice B, "This shot will help relieve the pain in your feet," is the best answer because it directly addresses the client's concern about the purpose of the medication. By explaining the potential benefit of the injection, the nurse can alleviate the client's anxiety and increase their cooperation during the procedure. Choice A is incorrect as it dismisses the client's question and may escalate the situation. Choice C is not suitable as it deviates from addressing the client's immediate query. Choice D is incorrect because it fails to specifically address the client's concern regarding the medication's purpose.
The nurse is providing discharge teaching to a client who has undergone abdominal surgery. What instruction should the nurse include?
- A. Avoid heavy lifting for at least 6 weeks
- B. Limit fluid intake to reduce the risk of infection
- C. Resume normal activities as soon as possible
- D. Avoid driving for at least 2 weeks
Correct Answer: A
Rationale: The correct answer is A: 'Avoid heavy lifting for at least 6 weeks.' After abdominal surgery, it is essential to avoid heavy lifting to prevent complications such as incisional hernias and support proper healing. Choice B, 'Limit fluid intake to reduce the risk of infection,' is incorrect because adequate fluid intake is necessary for wound healing and preventing dehydration. Choice C, 'Resume normal activities as soon as possible,' is incorrect as it may increase the risk of complications and delay healing. Choice D, 'Avoid driving for at least 2 weeks,' is incorrect as the restriction on driving may vary depending on the type of surgery and individual recovery.
Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will 'finally go away.' How should the nurse respond?
- A. Explain that healing from the injury can take many months.
- B. Assist the client in developing a goal of managing the pain.
- C. Encourage the client to verbalize her fears about the pain.
- D. Complete an assessment of the client's functional ability.
Correct Answer: B
Rationale: The correct answer is B: 'Assist the client in developing a goal of managing the pain.' In cases of chronic neuropathic pain, complete resolution is often not achievable. Therefore, the most appropriate approach is to help the client develop strategies to manage the pain effectively. Choice A is incorrect because it may give false hope of immediate resolution, which is unlikely with neuropathic pain. Choice C is incorrect as it does not directly address the client's need for pain management. Choice D is incorrect as it focuses on functional ability assessment, which is not the priority when addressing the client's pain concerns.
For a client with pneumonia, the prescription states, "Oxygen at liters/min per nasal cannula PRN difficult breathing." Which nursing intervention is effective in preventing oxygen toxicity?
- A. Avoiding the administration of oxygen at high levels for extended periods.
- B. Administering a sedative at bedtime to slow the client's respiratory rate.
- C. Removing the nasal cannula during the night to prevent oxygen buildup.
- D. Running oxygen through a hydration source prior to administration.
Correct Answer: A
Rationale: Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.