Nokea
A client who is diagnosed with cystitis has been given a prescription for phenazopyridine (Pyridium). She asks the nurse why she has been given this medication. What should the nurse reply?
- A. Pyridium is an antibiotic that will kill the bacteria causing your infection.'
- B. Pyridium is an analgesic that will make you less aware of the pain and discomfort.'
- C. Pyridium is a urinary tract anesthetic that will kill the pain until the antibiotics have had time to work.'
- D. Pyridium will help to prevent kidney damage from the bladder infection.'
Correct Answer: C
Rationale: Phenazopyridine is a urinary tract anesthetic, relieving pain and burning during urination until antibiotics resolve cystitis. It's not an antibiotic, analgesic, or kidney protectant.
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The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 90 bpm.
- C. Facial flushing and itching.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food?
- A. Hot dog pieces
- B. Sliced bananas
- C. Whole grapes
- D. Popcorn
Correct Answer: B
Rationale: Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and-mile occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
- A. Call a chaplain
- B. Deny the feelings
- C. Cite recovery statistics
- D. Listen to the client
Correct Answer: D
Rationale: Listen to the client. Therapeutic communications are based on attentive listening to expressed feelings, followed by questions about cultural beliefs if needed.
The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
- A. I can only wear cotton socks.'
- B. I cannot go barefoot around my house.'
- C. I will trim corns and calluses regularly.'
- D. I should ask a family member to inspect my feet daily.'
Correct Answer: C
Rationale: I will trim corns and calluses regularly.' Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.
A client with a perforated bowel secondary to a bowel obstruction.
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
- A. Maintain the client in a supine position.
- B. Notify the client's next-of-kin.
- C. Prepare the client for emergency surgery.
- D. Remove the nasogastric tube.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done