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A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?
- A. Chronic insomnia.
- B. Puffy, bleeding gums.
- C. Double vision.
- D. Blood pressure 100/78 mm Hg.
Correct Answer: C
Rationale: Double vision, or diplopia, can indicate phenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen.
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A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension signify a severe ABO incompatibility reaction, necessitating urgent reporting to prevent life-threatening complications such as renal failure or disseminated intravascular coagulation.
An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?
- A. Elevate the head of the bed.
- B. Initiate a bowel prep protocol for surgery.
- C. Educate the patient on increasing dietary fiber.
- D. Maintain the patient's NPO status.
Correct Answer: D
Rationale: Maintaining NPO status rests the bowel, promoting healing during acute diverticulitis.
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan?
- A. Eat a diet that is high in protein and vitamins A and C.
- B. Maintain bed rest as much as possible.
- C. Keep legs elevated when sitting or lying down.
- D. Inspect ankles daily for areas of darkening skin.
- E. Apply intermittent cold compresses four times daily.
Correct Answer: A,C,D
Rationale: A high-protein diet with vitamins A and C, leg elevation, and daily ankle inspections promote healing and monitor complications in venous leg ulcers.
The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient's pain?
- A. Activity level of bowel sounds.
- B. Level and amount of physical activity.
- C. Eating patterns of dietary intake.
- D. Color and consistency of feces.
Correct Answer: C
Rationale: Eating patterns identify foods that exacerbate pancreatitis pain, guiding dietary modifications.
Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?
- A. Keep the head of the bed elevated until the treatment is completed.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Monitor the client's intravenous site hourly during the treatment.
- D. Administer an antiemetic before starting the chemotherapy.
Correct Answer: C
Rationale: Hourly IV site monitoring allows early detection of extravasation, preventing tissue damage from vesicant chemotherapy.