Nokea
A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?
- A. Take the medication with meals
- B. Avoid alcohol while taking this medication
- C. Limit sodium intake
- D. Take the medication at bedtime
Correct Answer: B
Rationale: The correct answer is B: Avoid alcohol while taking this medication. Phenytoin interacts with alcohol, increasing the risk of side effects such as dizziness and drowsiness. Alcohol can also reduce the effectiveness of the medication. Taking the medication with meals (choice A) may help reduce gastrointestinal upset but does not address the alcohol interaction. Limiting sodium intake (choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (choice D) is not necessary for all clients and does not address the alcohol interaction.
You may also like to solve these questions
The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?
- A. Monitor daily weights
- B. Limit fluid intake to prevent fluid overload
- C. Report any weight gain of more than 2 pounds in a day
- D. Increase protein intake to promote healing
Correct Answer: C
Rationale: Rationale: Choice C is correct because sudden weight gain can indicate fluid retention, a common complication in chronic kidney disease. This can lead to serious issues like heart failure. Monitoring weight daily (A) is important, but specifically reporting significant gains promptly (C) is crucial. Limiting fluid intake (B) is important, but not the top priority. Increasing protein intake (D) may worsen kidney function, so it's not recommended.
An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?
- A. Have both nurses meet separately with the staff mental health consultant
- B. Listen actively to both nurses and offer suggestions to solve the dilemma
- C. Ask the senior nurse to examine mentoring strategies used with the new graduate
- D. Ask the nurses to meet with the nurse-manager to identify ways of working together
Correct Answer: D
Rationale: The correct answer is D. The nurse-manager should ask the nurses to meet to identify ways of working together. This is the best action because it promotes open communication, collaboration, and conflict resolution between the two nurses. By facilitating a discussion between them, the nurse-manager can help address the underlying issues, clarify misunderstandings, and find common ground for effective teamwork. This approach encourages mutual understanding and fosters a positive working relationship.
A: Having both nurses meet separately with the staff mental health consultant does not directly address the conflict between them.
B: While listening actively and offering suggestions is important, involving both nurses in the discussion is crucial for resolving the conflict.
C: Asking the senior nurse to examine mentoring strategies does not involve the new graduate in the conversation and may not address the overall issue.
A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
- A. Refer the client to a healthcare provider for a pelvic examination
- B. Notify the parents that the client needs to be picked up from school
- C. Determine the date of the client's last menstrual period
- D. Ask the client to lie down for a pelvic examination
Correct Answer: A
Rationale: The correct answer is A: Refer the client to a healthcare provider for a pelvic examination. This is the first action the nurse should take because the client is experiencing abdominal pain and dysmenorrhea, which could indicate a gynecological issue. A pelvic examination by a healthcare provider is necessary to assess for any potential reproductive system problems, such as ovarian cysts, endometriosis, or pelvic inflammatory disease. This examination will provide valuable information to diagnose and treat the underlying cause of the client's symptoms.
Choice B is incorrect because notifying the parents to pick up the client does not address the primary concern of evaluating the abdominal pain and dysmenorrhea. Choice C is also incorrect as determining the date of the client's last menstrual period, while important, does not take precedence over a thorough pelvic examination. Choice D is incorrect as asking the client to lie down for a pelvic examination should only be done by a healthcare provider in a proper clinical setting, not in a school clinic.
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: C
Rationale: Rationale:
1. Heparin primarily affects the intrinsic pathway of coagulation.
2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy.
3. INR is more specific for monitoring heparin therapy compared to other options.
4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring.
5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
- A. Wear long-sleeved clothing when outdoors
- B. Report the onset of sore throat
- C. Eat plenty of potassium-rich food
- D. Change the position slowly
Correct Answer: D
Rationale: The correct answer is D: Change the position slowly. Elderly clients taking both ACE inhibitors and calcium channel blockers are at risk for orthostatic hypotension. Instructing them to change positions slowly helps prevent sudden drops in blood pressure and dizziness upon standing up.
A: Wearing long-sleeved clothing when outdoors is not directly related to the medications mentioned.
B: Reporting the onset of a sore throat is important for monitoring potential side effects of medications but not specific to the combination of ACE inhibitors and calcium channel blockers.
C: Eating plenty of potassium-rich foods is not typically contraindicated for clients taking ACE inhibitors and calcium channel blockers, but it is not the most essential instruction compared to preventing orthostatic hypotension.
In summary, changing position slowly is crucial to prevent orthostatic hypotension, which is a common side effect of these medications in elderly clients.