Nokea
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
- A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use
- B. Nail polish should not be used near a client who is receiving oxygen
- C. A 'No smoking' sign should be placed on the front door
- D. Cotton bedding & clothing should be replaced with items made from wool
- E. A fire extinguisher should be readily available in the home
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Nail polish should not be used near a client who is receiving oxygen to prevent a fire hazard as it is flammable.
C: A 'No smoking' sign should be placed on the front door to remind visitors not to smoke near the oxygen source.
E: A fire extinguisher should be readily available in the home to handle any fire emergencies related to oxygen use.
Incorrect choices:
A: Family members who smoke must be at least 10 ft from the client when the oxygen is in use is not as crucial as preventing ignition sources like nail polish.
D: Replacing cotton bedding & clothing with wool is unnecessary for oxygen safety.
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A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?
- A. Cooked barley
- B. Pureed broccoli
- C. Vanilla custard
- D. Lentil soup
Correct Answer: C
Rationale: The correct answer is C: Vanilla custard. A low-residue diet aims to minimize fiber intake to reduce the bulk and frequency of bowel movements. Vanilla custard is low in fiber, making it suitable for this diet. Cooked barley (A) and lentil soup (D) are high in fiber and not recommended. Pureed broccoli (B) contains fiber and should be avoided. In summary, vanilla custard is the best choice for a low-residue diet due to its low fiber content compared to the other options.
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents.'
- B. It's been so stressful for me to even think about having my own family.'
- C. I don't even know who I am yet, & now I'm supposed to know what to do.'
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.'
Correct Answer: C
Rationale: The correct answer is C: "I don't even know who I am yet, & now I'm supposed to know what to do." This statement highlights an existential crisis and identity confusion, which are common developmental challenges in young adulthood. It indicates a lack of self-awareness and direction, which can significantly impact the individual's overall well-being and decision-making capabilities. Addressing this issue is crucial as it forms the foundation for addressing other concerns effectively. Choices A, B, and D focus on external stressors and specific situations, which are important but secondary to the core issue of self-identity. Therefore, prioritizing assessment and intervention for the client's self-identity crisis is essential to promote holistic growth and resolution of other challenges.
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
- A. Don't measure the client's temperature rectally.'
- B. Count the client's radial pulse for 30 seconds & multiply by 2.'
- C. Don't let the client know you are counting her respirations.'
- D. Let the client rest for 5 minutes before you measure her BP.'
Correct Answer: A
Rationale: Correct Answer: A: Don't measure the client's temperature rectally.
Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.
Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.
A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication administration record, which of the following medications should the nurse administer?
- A. Meperidine (Demerol) 75 mg IM
- B. Fentanyl 50 mcg/hr transdermal patch
- C. Morphine 2 mg IV
- D. Oxycodone 10 mg PO
Correct Answer: C
Rationale: The correct answer is C: Morphine 2 mg IV. Postoperative pain management is crucial for patient comfort and recovery. IV morphine is a potent opioid analgesic that provides quick and effective pain relief. The IV route allows for rapid onset of action, making it suitable for severe pain like in this case. Meperidine (choice A) is not recommended due to its toxic metabolite accumulation risk. Fentanyl patch (choice B) has a delayed onset and is not ideal for immediate pain relief. Oxycodone PO (choice D) is a less potent oral option compared to IV morphine for severe pain.
A nurse is reviewing the reported medications of a client who was recently admitted. The medications include cimetidine (Tagamet) and imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects?
- A. Decreased therapeutic effects of cimetidine
- B. Increased risk of imipramine hydrochloride toxicity
- C. Decreased risk of adverse effects of cimetidine
- D. Increased therapeutic effects of imipramine hydrochloride
Correct Answer: B
Rationale: The correct answer is B: Increased risk of imipramine hydrochloride toxicity. Cimetidine inhibits the metabolism of imipramine hydrochloride, leading to increased levels of imipramine in the body. This can result in a higher concentration of imipramine, potentially causing toxicity. This interaction is known as a pharmacokinetic drug-drug interaction.
Incorrect choices:
A: Decreased therapeutic effects of cimetidine - This is incorrect because cimetidine's therapeutic effects are not directly impacted by its interaction with imipramine.
C: Decreased risk of adverse effects of cimetidine - This is incorrect as there is no evidence to suggest that the interaction with imipramine decreases the risk of adverse effects of cimetidine.
D: Increased therapeutic effects of imipramine hydrochloride - This is incorrect as the increased risk of toxicity does not equate to increased therapeutic effects.