Nokea
A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?
- A. Diffuse muscle pain
- B. Flushing and pruritus
- C. Low blood pressure
- D. Wheezing and hives
Correct Answer: D
Rationale: Wheezing and hives (D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (A), flushing/pruritus (B), and low blood pressure (C) are less immediately life-threatening.
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The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema?
- A. A contrast medium is administered rectally to visualize the colon via x-ray'
- B. Bedridden clients receive this enema to stimulate defecation and relieve constipation.'
- C. This enema assists the large intestines in removing excess potassium from the body.'
- D. This enema is administered before bowel surgery to decrease bacteria in the colon.'
Correct Answer: C
Rationale: Sodium polystyrene sulfonate (C) removes excess potassium via the intestines, used in hyperkalemia. Other options describe unrelated procedures.
An adult client in an acute care facility says to the nurse, 'I hope this hospital doesn't have student doctors and nurses. I do not want a student taking care of me.' The nurse's response should be based on which of the following understandings?
- A. When a client signs permission for treatment in a hospital, this includes treatment by medical and nursing students.
- B. The client has the right to know if the hospital is affiliated with a medical school and to refuse care by students.
- C. The client may sign a special form that says he refuses to be cared for by medical or nursing students.
- D. The client should be informed if any caregivers are students, but the client does not have the right to refuse to be cared for by students.
Correct Answer: B
Rationale: Clients have the right to know about student involvement and refuse student care, respecting autonomy. Consent doesn't inherently include students, and special forms or mandatory acceptance are incorrect.
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?
- A. I've felt the need for an afternoon nap most days this week.'
- B. I've gained 3 lb (1.36 kg) since I began taking this medication.'
- C. I've had the stomach flu for the past couple of days.'
- D. My mouth seems to be drier than usual lately.'
Correct Answer: C
Rationale: Stomach flu (C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (A), weight gain (B), and dry mouth (D) are less urgent side effects.
A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply.
- A. Administer docusate sodium orally every day
- B. Assist in applying an abdominal binder
- C. Implement caloric restriction to promote weight loss
- D. Monitor blood glucose to maintain tight control
- E. Reinforce teaching to hug a pillow while coughing
Correct Answer: B, D, E
Rationale: Abdominal binder (B), glucose control (D), and pillow hugging (E) reduce wound stress and promote healing. Docusate (A) prevents constipation but not dehiscence, and caloric restriction (C) is inappropriate post-surgery.
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?
- A. Teach her how to meet the needs of self and her family
- B. Explain the changes in diet necessary for pregnant women
- C. Question her understanding and use of the food pyramid
- D. Conduct a diet history to determine her normal eating routines
Correct Answer: D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.