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A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct Answer: B
Rationale: A client taking an MAO Inhibitor, such as phenelzine (Nardil), should avoid tyramine-rich foods, which includes avocados, bananas, and salami.
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The client taking glyburide 5 mg orally once daily presents in the ED with headache, flushing, nausea, and abdominal cramps. The client's fingerstick blood sugar result is 56 mg/dL. Which question is most important for the nurse to ask the client?
- A. How many grams of protein do you normally eat?
- B. What time did you eat your dinner last night?
- C. How often do you check your blood sugar level?
- D. What was your alcohol intake like this past week?
Correct Answer: D
Rationale: A: Carbohydrate intake, not protein, is more important to consider in diabetic clients in relation to blood sugar levels. B: Glyburide once daily dose is taken with breakfast, so asking the client about dinner is not consistent with drug administration. C: Asking the client frequency of checking blood sugar levels will not help determine the possible causes of the client's symptoms. D: Alcohol use while taking sulfonylureas such as glyburide (DiaBeta, Micronase) can cause a disulfiram-like reaction, manifested by abdominal cramps, nausea, headache, flushing, and hypoglycemia.
The nurse is preparing to administer medications at 1700 to multiple clients with GI problems. Which medication should be the nurse's priority when the meal trays are due to arrive at 1700?
- A. Misoprostol
- B. Famotidine
- C. Cimetidine
- D. Bisacodyl
Correct Answer: A
Rationale: A: The nurse's priority should be to administer misoprostol (Cytotec), a gastric protectant, first because it should be taken with meals to minimize diarrhea. B: Famcomputers (Pepcid), a histamine receptor agonist, should be taken after meals. C: Cimetidine (Tagamet HB), a histamine receptor agonist, should be taken after meals. D: Bisacodyl (Dulcolax), a laxative, should be taken at least one hour after meals.
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary.
Correct Answer: D
Rationale: It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.
The nurse is observing a client self-administer two medications that are in a crushable pill form through their G tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler's position for 30 minutes following administration of the medications.
- C. The client mixes their medications with their tube-feeding formula.
- D. The client mixes each medication separately in warm water.
Correct Answer: C
Rationale: Medication should not be mixed with tube-feeding formula or other medications. The G-tube should be flushed before, between, and after the medications, and the client should remain in the Semi-Fowler's position for at least 30 minutes after medications are administered.
The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?
- A. eating breakfast
- B. drinking fluids
- C. getting out of bed to use the bathroom
- D. brushing teeth
Correct Answer: C
Rationale: Risperdal can cause orthostatic hypotension, so, to prevent a fall, care should be taken when changing positions.