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The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?
- A. Red man syndrome.
- B. Blood pressure of 130/80 mm Hg.
- C. Mild itching at the IV site.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A: Red man syndrome. This is a severe adverse reaction to vancomycin characterized by flushing, rash, hypotension, and tachycardia. It can progress rapidly to anaphylaxis. Immediate reporting is crucial for prompt intervention. Blood pressure of 130/80 mm Hg is within normal range, mild itching at the IV site is common and can be managed topically, and nausea and vomiting are common side effects of vancomycin but are not life-threatening compared to Red man syndrome.
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A healthcare provider is providing dietary teaching to a client with cholecystitis. Which type of diet should the healthcare provider recommend?
- A. High-fiber, low-fat diet
- B. Low-fiber, high-protein diet
- C. Low-fat, low-cholesterol diet
- D. High-protein, high-fat diet
Correct Answer: C
Rationale: The correct answer is C: Low-fat, low-cholesterol diet. For cholecystitis, which is inflammation of the gallbladder, a low-fat, low-cholesterol diet is essential to prevent exacerbation of symptoms. High-fat diets can trigger gallbladder attacks, while low-fat and low-cholesterol diets help reduce the workload on the gallbladder. High-fiber (choice A) may be too harsh on the digestive system. Low-fiber, high-protein (choice B) and high-protein, high-fat (choice D) diets can exacerbate symptoms due to the high-fat content.
A client with liver failure is at an increased risk of bleeding due to the inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?
- A. Alterations in glucose metabolism
- B. Retention of bile salts
- C. Inadequate production of albumin by hepatocytes
- D. Inability of the liver to use vitamin K
Correct Answer: D
Rationale: The correct answer is D: Inability of the liver to use vitamin K. Vitamin K is essential for the synthesis of clotting factors, including prothrombin. In liver failure, impaired function leads to reduced production of bile, which is necessary for the absorption of fat-soluble vitamins like vitamin K. This results in inadequate activation of clotting factors and increased risk of bleeding. Choices A, B, and C are incorrect as alterations in glucose metabolism, retention of bile salts, and inadequate albumin production do not directly impact the synthesis and activation of clotting factors like prothrombin in liver failure.
A client who is acutely ill has vigilant oral care included in their plan of care. What factor increases this client's risk for dental caries?
- A. Hormonal changes induced by the stress response leading to an acidic oral environment
- B. Systemic infections commonly affecting the teeth
- C. Intravenous hydration lacking fluoride
- D. Inadequate nutrition and reduced saliva production contributing to cavities
Correct Answer: D
Rationale: The correct answer is D because inadequate nutrition and reduced saliva production contribute to cavities. In acute illness, the client may not be able to consume a balanced diet, leading to nutrient deficiencies that weaken teeth. Reduced saliva flow decreases the mouth's ability to naturally clean and protect teeth. Choices A, B, and C are incorrect because hormonal changes from stress do not directly lead to acidic oral environment, systemic infections do not commonly affect teeth, and lack of fluoride from intravenous hydration is not a primary factor for dental caries.
A 60-year-old man presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?
- A. Type 1 diabetes mellitus
- B. Type 2 diabetes mellitus
- C. Diabetes insipidus
- D. Hyperthyroidism
Correct Answer: A
Rationale: The most likely diagnosis for a 60-year-old man with fatigue, polyuria, polydipsia, hyperglycemia, and ketonuria is Type 1 diabetes mellitus. The key clues are the presence of ketonuria, which indicates the body is breaking down fats for energy due to lack of insulin in Type 1 diabetes. Additionally, the acute onset of symptoms in an older individual suggests an autoimmune destruction of pancreatic beta cells seen in Type 1 diabetes. Type 2 diabetes is less likely due to the acute presentation and ketonuria. Diabetes insipidus presents with polyuria but not hyperglycemia or ketonuria. Hyperthyroidism typically presents with symptoms such as weight loss, tremors, and heat intolerance, not the classic symptoms seen in this case.
A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the client's teaching?
- A. Avoid alcohol while taking this medication.
- B. Take the medication with a full meal.
- C. Increase your intake of high-fiber foods.
- D. Avoid exposure to sunlight.
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol while taking this medication. Methotrexate can cause liver toxicity, and alcohol consumption can exacerbate this risk. It is important for the client to avoid alcohol to prevent potential harm to the liver.
B: Taking the medication with a full meal is not a necessary instruction for methotrexate. It is typically recommended to take methotrexate on an empty stomach.
C: Increasing intake of high-fiber foods is not directly related to methotrexate therapy. It is important for overall health but not specifically for this medication.
D: Avoiding exposure to sunlight is not a common instruction for methotrexate. While some medications can increase sensitivity to sunlight, this is not a typical concern with methotrexate.