Nokea
A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions?
- A. I will report a fever or sore throat to my doctor.
- B. Some joint pain is expected and is nothing to worry about.
- C. I must brush my teeth frequently to avoid damage to my gums.
- D. My urine may turn red in color, but this is nothing to be concerned about.
Correct Answer: A
Rationale: Carbamazepine is an anticonvulsant medication and is also used to alleviate the pain associated with trigeminal neuralgia. Agranulocytosis is an adverse effect of carbamazepine, and it places the client at risk for infection. If the client develops a fever or a sore throat, the primary health care provider should be notified. Unusual bruising and bleeding are also adverse effects of the medication, and they need to be reported to the primary health care provider if they occur.
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The nurse has taught a client with a below-the-knee amputation about home care and about monitoring for and preventing complications related to prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that which action should be taken?
- A. Wear a clean nylon sock over the residual limb every day.
- B. Use a mirror to inspect all areas of the residual limb each day.
- C. Toughen the skin of the residual limb by rubbing it with alcohol.
- D. Prevent cracking of the skin of the residual limb by applying lotion daily.
Correct Answer: B
Rationale: The client should inspect all surfaces of the residual limb daily for irritation, blisters, and breakdown. The client should wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe prosthesis use.
A 28-year-old client has just given birth. At one minute the baby appears healthy, with the exception of bluish hands. Which of the following would the nurse midwife pronounce?
- A. The Apgar score is 11.
- B. The Apgar score is 9.
- C. The Apgar score is 6.
- D. The Apgar score is 4.
Correct Answer: B
Rationale: The Apgar score assesses appearance, pulse, grimace, activity, and respiration, with a maximum of 10. Bluish hands indicate acrocyanosis, common in newborns, deducting 1 point from appearance, resulting in a score of 9 if other parameters are normal. Option A is impossible, and C and D are too low for a healthy baby.
A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction?
- A. Cleanse the perineal area with soap and water once a day.
- B. Keep the drainage bag lower than the level of the bladder.
- C. Limit fluid intake so that the bag will not become full so quickly.
- D. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.
Correct Answer: B
Rationale: Keeping the drainage bag lower than the bladder prevents urine backflow, reducing infection risk. The perineal area should be cleansed twice daily and after bowel movements. Adequate fluid intake is necessary to prevent infection, and coiling tubing under the thigh can obstruct drainage.
The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions should the nurse teach the client to follow?
- A. Keep glucose tablets.
- B. Monitor the urine for acetone.
- C. Report any feelings of drowsiness.
- D. Omit the evening dose of NPH insulin if the client has been exercising.
Correct Answer: A
Rationale: Glucose tablets are taken if a hypoglycemic reaction occurs. Glucagon is also a medication that may be prescribed to be administered subcutaneously or intramuscularly if the client loses consciousness and is unable to take glucose by mouth. Glucagon releases glycogen stores and raises the blood glucose levels of hypoglycemic clients. Family members can be taught to administer this medication and possibly to prevent an emergency department visit. Acetone in the urine may indicate hyperglycemia. Although signs/symptoms of hypoglycemia need to be taught to the client, drowsiness is not the initial and key sign of this complication. The nurse should not instruct a client to omit insulin.
A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?
- A. Do nothing; this is a normal response
- B. Strip the tubing to remove any clots
- C. Place a clamp on the tube near the client's chest
- D. Remove the collection chamber and connect the tubing to a new device
Correct Answer: C
Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately.
Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak. Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action. Choice D is incorrect as it does not address the immediate need to locate and address the leak.