A 27-year-old female is admitted for elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact?
- A. Complaints of nausea.
- B. Repeated swallowing.
- C. Rapid respiratory rate.
- D. Feelings of anxiety.
Correct Answer: B
Rationale: Repeated swallowing may indicate postnasal bleeding, as blood may flow down the throat rather than out the nose, even if the nasal drip pad remains dry.
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The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect?
- A. Decreased urine alkaline phosphatase level.
- B. Increased urine calcium excretion.
- C. Increased serum calcium level.
- D. Decreased serum uric acid level.
Correct Answer: D
Rationale: Allopurinol reduces serum uric acid levels, indicating therapeutic effectiveness in preventing uric acid stone formation.
An African-American woman had experienced severe palpitations, weakness, and shortness of breath after taking bacitracin (Bactrim). As a part of the discharge planning, the nurse should evaluate the client's knowledge about:
- A. Increased folic acid needs.
- B. Congenital enzyme deficiency.
- C. Restricted activity in hot weather.
- D. Need for blood transfusions.
Correct Answer: B
Rationale: Bactrim (sulfamethoxazole/trimethoprim) can cause hemolytic anemia in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency, a congenital enzyme deficiency common in African-American populations. The nurse should assess the client's understanding of G6PD deficiency and how to avoid triggers like certain medications. Folic acid, activity restrictions, and transfusions are not directly related.
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids?
- A. Take your medication with a full glass of water.'
- B. Take your medication on an empty stomach.'
- C. Take your medication at bedtime to increase absorption.'
- D. Take your medication with meals or with an antacid.'
Correct Answer: D
Rationale: Taking glucocorticoids with meals or an antacid reduces gastrointestinal irritation, a common side effect.
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