Nokea
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
- A. We will call the health care provider if the child develops acne.'
- B. Our child should brush and floss carefully after every meal.'
- C. We will skip the next dose if vomiting or fever occur.'
- D. When our child is seizure-free for 6 months, we can stop the medication.'
Correct Answer: B
Rationale: Our child should brush and floss carefully after every meal.' Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.
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The nurse assesses a 72 year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
- A. Decreased urinary output
- B. Jugular vein distention
- C. Pleural effusion
- D. Bibasilar crackles
Correct Answer: B
Rationale: Signs of right-sided heart failure include jugular vein distention, ascites, nausea, and vomiting.
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?
- A. Bleeding time
- B. Hemoglobin and hematocrit
- C. White blood cells
- D. Platelets
Correct Answer: B
Rationale: Hemoglobin and hematocrit. The post-transfusion hematocrit provides immediate information about red cell replacement and about continued blood loss.
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
- A. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
- B. It is critical to report promptly to your health care provider any findings of peptic ulcers
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
- D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
Correct Answer: B
Rationale: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite.
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.