Nokea
A client with tuberculosis is started on Rifampin. Which one of the following statements by the nurse would be appropriate to include in teaching? 'You may notice:
- A. an orange-red color to your urine.'
- B. your appetite may increase for the first week.'
- C. it is common to experience occasional sleep disturbances.'
- D. if you take the medication with food, you may have nausea.'
Correct Answer: A
Rationale: Discoloration of the urine and other body fluids may occur. It is a harmless response to the drug, but the patient needs to be aware it may happen.
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A student nurse caring for a client while wearing a gown and gloves in addition to following standard precautions.
The nurse should determine that care is appropriate if the student nurse performs which of the following activities?
- A. Gives isoniazid (INH) to a client with tuberculosis.
- B. Administers an IM injection to a client with rubella.
- C. Delivers a food tray to a client with hepatitis.
- D. Changes the dressing for a client with a draining abscess.
Correct Answer: D
Rationale: Strategy: Determine how the organism of each disease is spread. (1) requires airborne precautions, particulate respirator (2) requires droplet precautions, nurse should wear a mask (3) requires standard precautions (4) correct-requires contact precautions
To minimize the side effects of a DPT immunization for a six-month-old.
The nurse should instruct the parents to
- A. give the child an alcohol bath for an elevated temperature.
- B. administer antipyretics for discomfort, irritability, and fever.
- C. place an ice bag on the child's leg for one hour.
- D. check the child's temperature every four hours for three days.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, uncomfortable and unnecessary (2) correct-implementation, antipyretics relieve the combination of side effects (3) implementation, dangerous to both skin integrity and overall temperature control (4) assessment, unnecessary unless indicated for another reason
A client in labor is receiving magnesium sulfate IV.
Which assessment is MOST important to give during report to the nurse on the next shift?
- A. Respiratory rate changed from 13/min to 15/min.
- B. Increase in anxiety and hyperactivity.
- C. Presence of nausea and refusal to take clear liquids.
- D. Urine output decreased from 60 cc/h to 40 cc/h.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to magnesium sulfate. (1) not a concern because the respirations are increasing (2) not relevant to the medication (3) not relevant to the medication (4) correct-magnesium sulfate is a central nervous system depressant; side effect is oliguria
A client who has a panic disorder is receiving paroxetine HCl (Paxil). The client has been taking the drug for one week and is still having severe panic attacks. The client tells the nurse that she thinks the drug is not working. What is the best response for the nurse to make?
- A. You should ask your physician for a different drug.
- B. The physician will probably add another drug to your regimen.
- C. You should stop taking the medication if it is not effective.
- D. It takes two to four weeks for Paxil to be effective.
Correct Answer: D
Rationale: Paroxetine, an SSRI, requires 2-4 weeks to reach therapeutic effect for panic disorder, explaining the continued symptoms.
A client who is diagnosed with cystitis has been given a prescription for phenazopyridine (Pyridium). She asks the nurse why she has been given this medication. What should the nurse reply?
- A. Pyridium is an antibiotic that will kill the bacteria causing your infection.'
- B. Pyridium is an analgesic that will make you less aware of the pain and discomfort.'
- C. Pyridium is a urinary tract anesthetic that will kill the pain until the antibiotics have had time to work.'
- D. Pyridium will help to prevent kidney damage from the bladder infection.'
Correct Answer: C
Rationale: Phenazopyridine is a urinary tract anesthetic, relieving pain and burning during urination until antibiotics resolve cystitis. It's not an antibiotic, analgesic, or kidney protectant.