Nokea
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
- A. If he develops diarrhea lasting for more than 2-3 days, I will contact the doctor or nurse.
- B. I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.
- C. It is important to keep the head of his bed elevated or sit him in the chair during feedings.
- D. I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.
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Which of the following activities have been associated with an increase in lead exposure?
- A. Working with stained glass
- B. Drinking from disposable water bottles
- C. Restoring collectible toys
- D. Drinking coffee and tea from decorative ceramic mugs
- E. Using non-stick cookware
- F. Residing in a home constructed before 1950
Correct Answer: A, C, D, F
Rationale: Lead exposure risks include stained glass work (A), restoring old toys (C), decorative mugs (D), and pre-1950 homes (F) due to lead-based paint or glazes. Disposable bottles (B) and non-stick cookware (E) are not significant sources.
The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. Walk about a mile a day to prevent calcium loss.'
- B. Increase the fiber in your diet.'
- C. Report nausea to the doctor immediately.'
- D. Drink at least eight large glasses of water a day.'
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so adequate hydration (e.g., 8 glasses of water daily) is essential to flush the bladder and reduce this risk. Walking, fiber, and nausea reporting are not primary concerns with this drug.
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
- A. Stephens-Johnson syndrome
- B. Folate deficiency
- C. Leukopenic aplastic anemia
- D. Granulocytosis and nephrosis
Correct Answer: A
Rationale: Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
A client with a history of seizure disorder is admitted with complaints of breakthrough seizures. The nurse should give priority to:
- A. Administering anticonvulsants
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring respiratory rate
Correct Answer: A
Rationale: Administering anticonvulsants is the priority to control breakthrough seizures and prevent status epilepticus.
A client with a history of gout is receiving Allopurinol (Zyloprim). The nurse should teach the client to:
- A. Increase fluid intake
- B. Avoid dairy products
- C. Take the medication on an empty stomach
- D. Limit protein intake
Correct Answer: A
Rationale: Allopurinol reduces uric acid, and increased fluid intake promotes uric acid excretion, preventing kidney stones. Dairy, empty stomach, and protein limits are not necessary.