Nokea
A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg three times daily. The nurse should instruct the client to report which of the following side effects to the physician?
- A. Mild nausea after taking the medication.
- B. Gingival hyperplasia and rash.
- C. Slight drowsiness in the morning.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: gingival hyperplasia and rash are significant side effects of phenytoin that require medical attention
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The nurse is admitting a client directly from a health provider's office. The client has a rash and has been diagnosed with measles. Which room assignment by the nurse indicates an understanding of the disease process of measles?
- A. a private negative-pressure room
- B. a semiprivate room with a client who has a broken femur
- C. a semiprivate room with a client diagnosed with type 1 diabetes
- D. a private room at the end of the hall away from the nurses' station
Correct Answer: A
Rationale: Measles requires airborne precautions, necessitating a private negative-pressure room to prevent transmission.
The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
- A. Intravenously
- B. Rectally
- C. Intramuscularly
- D. Into the cerebrospinal fluid
Correct Answer: D
Rationale: Intrathecal administration involves delivering medication directly into the cerebrospinal fluid, typically via a spinal injection, to target the central nervous system effectively.
The nurse is caring for a homeless client diagnosed with right-sided heart failure. The nurse anticipates that upon discharge the client will need assistance regarding medications, locating a shelter, and follow-up to ensure that the client can obtain transportation to the next appointment with the cardiologist. The nurse understands that this is an example of which content area of care management?
- A. advocacy
- B. delegation
- C. ethical practice
- D. continuity of care
- E. advance directive
Correct Answer: D
Rationale: Arranging post-discharge support for medications, shelter, and follow-up ensures continuity of care for a vulnerable client.
The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should:
- A. Document the finding and continue to monitor the client
- B. Irrigate the drainage tube with 10 mL of normal saline
- C. Decrease the amount of intermittent suction
- D. Notify the physician of the findings
Correct Answer: D
Rationale: Increased bile-tinged drainage may indicate a complication, such as a leak, requiring physician notification.
If the nurse is unable to elicit the deep tendon reflexes of the patella, the nurse should ask the client to:
- A. Pull against the palms
- B. Grimace the facial muscles
- C. Cross the legs at the ankles
- D. Perform Valsalva maneuver
Correct Answer: A
Rationale: Pulling against the palms enhances reflex response by increasing muscle tone, aiding in eliciting the patellar reflex.