Nokea
A client is receiving intravenous (IV) antibiotic therapy at home via an intermittent IV catheter. In order to facilitate the early detection of IV therapy complications, which intervention should be included in the client's education?
- A. Protect the IV site continually.
- B. Keep the IV site clean and dry.
- C. Report local pain, drainage, or edema.
- D. Apply pressure to the IV site if it dislodges.
Correct Answer: C
Rationale: The nurse instructs the client to report clinical indicators of an IV site infection, including pain, drainage, and edema because the early detection of infection decreases the risk of septicemia, tissue loss, and devastating complications. The remaining options are reasonable aspects of client teaching for IV therapy at home, but they are not surveillance methods.
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Disulfiram has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching?
- A. I must be careful taking cold medicines.
- B. I will have to check my aftershave lotion.
- C. I'll be fine as long as I don't drink alcohol.
- D. I need to be careful with ingredients when I cook.
Correct Answer: C
Rationale: Clients who are taking disulfiram must be taught that substances that contain alcohol can trigger an adverse reaction. Sources of hidden alcohol include foods (soups, sauces, and vinegars), medicine (cold medicine), mouthwashes, and skin preparations (alcohol rubs and aftershave lotions).
The nurse is giving medication instructions to a client who is receiving furosemide. Which client statement indicates a need for further teaching?
- A. I need to change positions slowly.
- B. I need to be careful to not get overheated in warm weather.
- C. I need to talk to my primary health care provider about the use of alcohol.
- D. I need to avoid the use of salt substitutes because they contain potassium.
Correct Answer: D
Rationale: Furosemide is a potassium-losing diuretic, so there is no need to avoid high-potassium products, such as a salt substitute. Orthostatic hypotension is a risk, and the client must use caution when changing positions and with exposure to warm weather. The client needs to discuss the use of alcohol with the primary health care provider.
A client has had same-day surgery to insert a ventilating tube into the tympanic membrane. Which statement assures the nurse that the client understands the discharge instructions?
- A. I will use a shower cap when taking a shower.
- B. I was told to try and avoid taking medications for pain.
- C. I need to wash my hair quickly; taking 2 minutes or less.
- D. Swimming is allowed only if I keep my head above water.
Correct Answer: A
Rationale: After the insertion of tubes into the tympanic membrane, it is important to avoid getting water in the ears. A shower cap or earplug may be used when showering if allowed by the primary health care provider. Swimming, showering without a shower cap or ear plugs, and washing the hair are avoided after surgery until the time frame designated for each is identified by the surgeon. The client should take medication as advised for postoperative discomfort.
The nurse has given instructions about site care to a hemodialysis client who had an implantation of an arteriovenous (AV) fistula in the right arm. Which statement by the client indicates a need for further teaching?
- A. I will need to sleep on my right side.
- B. It's important that I don't carry heavy objects with the right arm.
- C. I will perform range-of-motion exercises routinely on my right arm.
- D. It's important that I report any right arm redness or drainage at the site.
Correct Answer: A
Rationale: Routine instructions to the client with an AV fistula, graft, or shunt include avoiding sleeping with the body weight on the extremity with the access site, avoiding carrying heavy objects or compressing the extremity that has the access site, performing routine range-of-motion exercises of the affected extremity, and reporting signs and symptoms of infection.
The nurse instructs a client diagnosed with oral candidiasis (thrush) about caring for the disorder. Which statement by the client indicates a need for additional teaching?
- A. I can eat foods that are liquid or pureed.
- B. I should eliminate spicy foods from my diet.
- C. It's best if I don't drink citrus juices or hot liquids.
- D. I need to rinse my mouth four times daily with commercial mouthwash.
Correct Answer: D
Rationale: Clients with thrush cannot tolerate commercial mouthwashes because the high alcohol concentration in these products can cause pain and discomfort of the lesions. A solution of warm water or mouthwash formulas without alcohol are better tolerated and may promote healing. A change in diet to liquid or pureed food often eases the discomfort of eating. The client should avoid spicy foods, citrus juices, and hot liquids.