Nokea
A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
- A. Gastric distress
- B. Changes in hearing
- C. Red discoloration of body fluids
- D. Changes in color vision
Correct Answer: D
Rationale: Ethambutol can cause optic neuritis, leading to changes in color vision, a serious side effect requiring immediate medical attention.
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A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:
- A. Prevent the development of acute respiratory failure
- B. Decrease cerebral blood flow
- C. Increase systemic tissue perfusion
- D. Prevent cerebral anoxia
Correct Answer: B
Rationale: Hyperventilation reduces PaCO2, causing vasoconstriction and decreasing cerebral blood flow to reduce intracranial pressure.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
- A. 16-year-old female with scoliosis
- B. 12-year-old male with a fractured femur
- C. 10-year-old male with sarcoma
- D. 6-year-old male with osteomylitis
Correct Answer: B
Rationale: A 12-year-old male with a similar condition provides age-appropriate companionship and shared care needs.
Upon entering the client's room the nurse discovers a dose of amoxicillin at the bedside. Which of the following should the nurse do?
- A. file an incident report and document the finding in the client's medical record
- B. document the finding in the client's medical record only
- C. report the incident to the nursing supervisor
- D. file an incident report but do not document the finding in the client's medical record
Correct Answer: A
Rationale: Documenting in the medical record and filing an incident report address the medication error and ensure follow-up for patient safety.
A client with pulmonary edema is ordered IV hydrocortisone (Solu-Cortef) 40 mg b.i.d. Which laboratory value would the nurse expect to see as a result of this therapy?
- A. elevated magnesium
- B. lowered magnesium
- C. elevated glucose
- D. lowered glucose
Correct Answer: C
Rationale: Hydrocortisone, a corticosteroid, increases blood glucose by promoting gluconeogenesis. Magnesium levels are not primarily affected.
A client with AIDS has impaired nutrition because of diarrhea. Which diet selection by the client would indicate a need for further teaching of foods that can worsen the diarrhea?
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw vegetables in a tossed salad can exacerbate diarrhea in AIDS patients. Baked chicken, broiled fish, and steamed rice are easier to digest and less likely to worsen diarrhea.