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The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take?
- A. Obtain the client's blood pressure.
- B. Check the client's pancreatic enzyme levels.
- C. Verify placement of the tube after administering the medication.
- D. Holdphysics://www.youtube.com/watch?v=9Q7sE1Xh_1QHold the enteral feeding for 1 hour before administering the medication.
Correct Answer: D
Rationale: Phenytoin binds to enteral feedings, reducing absorption. Holding feedings for 1 hour before and after administration ensures efficacy. Tube placement should be verified before, not after, administration. Blood pressure and pancreatic enzymes are unrelated.
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An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?
- A. The client has a false-positive reaction due to advanced age
- B. The client has a tuberculosis infection
- C. The client has active tuberculosis disease
- D. The client must be isolated immediately
Correct Answer: B
Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.
The nurse has reinforced teaching with the parent of a pediatric client with newly diagnosed hemophilia A. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using icepacks if my child is injured.
- B. I should provide a high-fat, high-protein diet for my child.
- C. My child should wear emergency medical identification at all times.
- D. My child can participate in noncontact sports such as swimming.
- E. I should avoid giving my child medication containing aspirin.
Correct Answer: C,D,E
Rationale: Medical identification ensures prompt treatment in emergencies. Noncontact sports like swimming are safe. Aspirin increases bleeding risk and should be avoided. Ice packs are beneficial for injuries to reduce swelling, and diet doesn't require high-fat/protein for hemophilia management.
The nurse is observing a nursing assistant transfer a client from bed to chair. Which observation needs correction? Select all that apply.
- A. The nursing assistant lowers the bed before starting the procedure.
- B. The nursing assistant sits the client on the side of the bed before assisting the client to move.
- C. The nursing assistant stands with feet close together and knees and back straight when helping the client to move.
- D. The nursing assistant asks the client to grab the arm of the nursing assistant during the transfer.
- E. The nursing assistant lifts the client up by tugging on the client's arms.
- F. The nursing assistant assists the client to stand and pivot to get into the chair.
Correct Answer: C,D,E
Rationale: The nursing assistant should stand with feet apart and knees bent to prevent injury, not grab the client's arm, and avoid tugging on the client's arms. Lowering the bed, sitting the client up, and assisting to pivot are correct.
The nurse has reinforced teaching with a client who has anxiety and a new prescription for alprazolam. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can continue to take my prescribed muscle relaxant as needed.
- B. I can omit the medication on days when I do not feel anxious.
- C. I should eliminate aged cheese and processed meats from my diet.
- D. I will discontinue the medication and notify my health care provider if I become pregnant.
Correct Answer: D
Rationale: Alprazolam is a benzodiazepine, and its use during pregnancy can pose risks to the fetus. Discontinuing and notifying the provider is critical. Muscle relaxants may enhance sedation, skipping doses disrupts therapeutic levels, and dietary restrictions like avoiding tyramine are not required for alprazolam.
The nurse is reinforcing discharge teaching to several clients with new prescriptions. Which instructions by the nurse about medication administration are correct? Select all that apply.
- A. Avoid salt substitutes when taking valsartan for hypertension
- B. Take levofloxacin with an aluminum antacid to avoid gastric irritation
- C. Take sucralfate (for a gastric ulcer) after meals to minimize gastric irritation
- D. When taking ethambutol, notify the health care provider (HCP) for changes in vision
- E. When taking rifampin, notify the HCP if the urine turns red-orange in color
Correct Answer: A,D
Rationale: Salt substitutes (potassium-based) can cause hyperkalemia with valsartan. Ethambutol can cause optic neuritis, requiring vision change reports. Levofloxacin with antacids reduces absorption. Sucralfate is taken before meals to coat the stomach. Rifampin's red-orange urine is normal, not reportable.