Nokea
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
- A. Prevent systemic infection
- B. Promote diuresis
- C. Decrease ammonia formation
- D. Acidify the small bowel
Correct Answer: C
Rationale: Neomycin is an antibiotic, but this is not the rationale for administering it to a client in hepatic coma. Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted.
You may also like to solve these questions
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron. Tomatoes provide vitamin C, which aids iron absorption, but lack significant iron content.
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
- A. Libel
- B. Slander
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
A female client comes for her second prenatal visit. The nurse-midwife tells her, 'Your blood tests reveal that you do not show immunity to the German measles.' Which notation will the nurse include in her plan of care for the client? 'Will need . . .
- A. Rh-immune globulin at the next visit'
- B. Rh-immune globulin within 3 days of delivery'
- C. Rubella vaccine at the next visit'
- D. Rubella vaccine after delivery on the day of discharge'
Correct Answer: D
Rationale: Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. The rubella vaccine is not given during pregnancy because of its teratogenicity. Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.
The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse's response is based on the knowledge that sufficient sphincter control for toilet training is present by:
- A. 12-15 months of age
- B. 18-24 months of age
- C. 26-30 months of age
- D. 32-36 months of age
Correct Answer: B
Rationale: Sufficient sphincter control for toilet training typically develops between 18-24 months, when children gain the physical and cognitive ability to control urination and defecation.
The pediatric nurse charts that the parents of a 4-year-old child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
- A. Discussing their needs with the nursing staff
- B. Discussing their needs with other family members
- C. Seeking support from their minister
- D. Refusing to participate in the child's care
Correct Answer: D
Rationale: (A, B, C) These methods are healthy ways of dealing with anxiety. Participation minimizes feelings of helplessness and powerlessness. It is important that parents have accurate information and that they seek support from sources available to them.