Nokea
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
- A. Change in libido, breast enlargement
- B. Sore throat, fever
- C. Abdominal pain, nausea, diarrhea
- D. Dsypnea, nasal congestion
Correct Answer: B
Rationale: The correct answer is B: "Sore throat and fever." These symptoms can indicate a serious side effect of chlorpromazine and should be reported immediately. Choices A, C, and D are incorrect because they are not typically associated with adverse effects of chlorpromazine. Changes in libido and breast enlargement are not commonly linked to this medication. Abdominal pain, nausea, and diarrhea are more likely to be gastrointestinal side effects. Dyspnea and nasal congestion are not commonly reported adverse effects of chlorpromazine.
You may also like to solve these questions
After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?
- A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: The most appropriate meal plan for a client following a myocardial infarction and placed on a sodium-restricted diet should include fresh ingredients with low sodium content to promote heart health. Option D, which consists of 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange, aligns best with these requirements. Option A contains canned beets, which are typically high in sodium. Option B includes canned salmon, which may have added sodium. Option C has a bologna sandwich, which is processed and high in sodium. Therefore, Option D is the most suitable choice for a client needing a low-sodium diet after a heart attack.
A 20-year-old client has an infected leg wound from a motorcycle accident and has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:
- A. Visitors must wear a mask and a gown
- B. There are no special requirements for visitors of clients on contact precautions
- C. Visitors should wash their hands before and after touching the client
- D. Visitors -
Correct Answer: C
Rationale: The correct answer is C: 'Visitors should wash their hands before and after touching the client.' When a client is on contact precautions, it is essential for visitors to practice good hand hygiene to prevent the spread of infection. While wearing a mask and a gown might be necessary for healthcare providers, it is not typically required for visitors. Option B is incorrect because there are indeed special requirements for visitors on contact precautions, including practicing good hand hygiene. Option D is incomplete and does not provide any guidance on infection prevention measures.
An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the ventrogluteal site
- C. call to get a smaller volume ordered
- D. check with the pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: Administering the medication in 2 separate injections is the correct action. When the total volume of an injection is relatively large for a specific site, dividing it into smaller volumes and administering them separately is a safer practice to prevent discomfort, tissue damage, or absorption issues. Giving the medication in the ventrogluteal site can be appropriate for IM injections but does not address the issue of the total volume being too high for a single injection. Calling to get a smaller volume ordered may delay treatment and is not necessary when a safe administration method is available. Checking with the pharmacy for a liquid form of the medication does not directly address the issue of the total volume being too high for a single injection, and changing the formulation may not be necessary if the correct administration technique can be applied.
A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?
- A. Apply appropriate signs outside and inside the room
- B. Apply a mask with a shield if there is a risk of fluid splash
- C. Wear a gown to change soiled linens from incontinence
- D. Have gloves on while handling bedpans with feces
Correct Answer: D
Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.
A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
- A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
- D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.
Correct Answer: A
Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.