Nokea
A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid exposure to sunlight while taking this medication.
- C. Report any numbness or tingling in extremities.
- D. Have liver function tests done regularly.
Correct Answer: D
Rationale: Step 1: Isoniazid (INH) can cause liver toxicity.
Step 2: Regular liver function tests help monitor for liver damage.
Step 3: Monitoring liver function is crucial to prevent serious complications.
Step 4: Other choices are not directly related to INH's side effects.
Summary: Choice D is correct as it directly addresses a potential serious side effect of INH. Choices A, B, and C are not directly relevant to the medication's side effects.
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Why are older adults more likely to develop hypovolemic shock?
- A. Low-activity lifestyle
- B. Altered cardiac function
- C. Decreased percentage of body water
- D. Decline in muscle strength and bone mass
Correct Answer: C
Rationale: Older adults have less total body water, making them more susceptible to fluid losses and hypovolemic shock.
What should the nurse instruct Mr. Ross to withhold food and fluid for several hours until after fiberoptic bronchoscopy?
- A. Sputum returns to normal color and consistency
- B. Speech returns to the normal pattern
- C. Vital signs become stable
- D. Cough reflex is present
Correct Answer: D
Rationale: A functioning cough reflex prevents aspiration.
Match the phases of the nursing process with the descriptions (phases may be used more than once).
- A. None
- B. Analysis of data
- C. Priority setting
- D. Nursing interventions
Correct Answer: B
Rationale: Analysis of data corresponds to the Diagnosis phase, where health problems are identified based on assessed data.
The most common, preventable complication of abdominal surgery is
- A. atelectasis.
- B. fluid and electrolyte imbalance.
- C. thrombophlebitis.
- D. urinary retention.
Correct Answer: D
Rationale: Urinary retention is a common issue post-abdominal surgery due to anesthesia effects and immobility.
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
- A. 1530 (3:30 PM)
- B. 1600 (4:00 PM)
- C. 1630 (4:30 PM)
- D. 1700 (5:00 PM)
Correct Answer: C
Rationale: The correct answer is C: 1630 (4:30 PM). The rationale is as follows:
1. The standard guideline for performing percutaneous coronary intervention (PCI) in acute MI is within 90 minutes of arrival at the hospital.
2. The client arrived at 1500 (3:00 PM), so adding 90 minutes to this time gives us 1630 (4:30 PM).
3. This timing aligns with The Joint Commission's Core Measures for timely PCI in acute MI cases.
4. Therefore, the correct time for the client to have PCI performed is 1630 (4:30 PM).
In summary, choices A, B, and D are incorrect because they do not align with the 90-minute guideline for performing PCI in acute MI cases, as mandated by The Joint Commission's Core Measures.