Nokea
A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report:
- A. Severe headache
- B. Slight nausea
- C. Decreased urination
- D. Itching
Correct Answer: A
Rationale: Erythropoietin can increase blood viscosity, raising the risk of hypertension or thrombosis, which may present as a severe headache. Slight nausea , decreased urination , and itching are less specific or urgent.
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Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.
- A. I will clarify with my health care provider before taking enteric-coated medications.
- B. I will irrigate the colostomy to promote regular bowel movements.
- C. I will limit eating foods such as broccoli and cauliflower to reduce odor.
- D. I will restrict my fluid intake to 2,000 milliliters of fluid a day.
- E. I will wait for the pouch to become completely full before emptying the contents.
Correct Answer: A,C
Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.
The nurse is caring for a client who has a prescription for cefuroxime 30 mg/kg/day PO in 2 divided doses. The client weighs 35 lb (15.9 kg). The nurse has cefuroxime 250 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 1 decimal place.
Correct Answer: 2.9
Rationale: Total daily dose: 30 mg/kg × 15.9 kg = 477 mg/day. Divided into 2 doses: 477 ÷ 2 = 238.5 mg/dose. Using 250 mg/5 mL: (238.5 mg ÷ 250 mg) × 5 mL = 4.77 mL. Per 2 doses: 4.77 ÷ 2 = 2.385, rounded to 2.9 mL per dose.
Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?
- A. Risk for self-injury
- B. Identity disturbance
- C. Self-esteem disturbance
- D. Sensory-perceptual alteration
Correct Answer: D
Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.
The nurse is talking with the parent of a pediatric client with attention deficit hyperactivity disorder who has a new prescription for methylphenidate. The parent asks, 'How will I know that the medication is effective?' Which of the following responses would be appropriate for the nurse to make?
- A. Your child will be less irritable.
- B. Your child will sleep longer at night.
- C. Your child will experience an increased appetite.
- D. Your child will complete tasks more easily and efficiently.
Correct Answer: D
Rationale: Methylphenidate improves focus and task completion in ADHD. It may increase irritability or decrease appetite as side effects, and sleep patterns vary but aren't a primary indicator of effectiveness.
The nurse is reinforcing discharge teaching for a client who has a low health literacy level. Which of the following actions should the nurse take? Select all that apply.
- A. Provide as much detail as possible.
- B. Utilize the teach-back method.
- C. Repeat important information.
- D. Use visual aids.
- E. Speak loudly.
Correct Answer: B,C,D
Rationale: Teach-back confirms understanding, repeating key points reinforces learning, and visual aids simplify concepts. Excessive detail overwhelms low-literacy clients, and loud speech is unnecessary unless hearing-impaired.