Nokea
A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least
- A. every 15 minutes.
- B. every 30 minutes.
- C. every hour.
- D. every 2 hours.
Correct Answer: C
Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (C) balance safety and practicality.
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A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
- A. Determine whether the ear infection has affected her hearing
- B. Make sure that she has taken all the antibiotic
- C. Document that the infection has completely cleared
- D. Obtain a new prescription, in case the infection recurs
Correct Answer: C
Rationale: A recheck appointment confirms that the otitis media has resolved, ensuring no residual infection or complications.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John's wort seldom relieves depression.
- B. She should avoid eating aged cheese.
- C. Skin reactions increase with the use of sunscreen.
- D. The herbal is safe to use with other antidepressants.
Correct Answer: C
Rationale: St. John's wort can cause photosensitivity, increasing the risk of skin reactions, so sunscreen use is recommended, not avoided.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
A client with recurrent episodes of gout has been advised to eat a low-purine diet. Which of the following foods should the nurse advise him to limit or avoid? Select all that apply.
- A. Liver.
- B. Sardines.
- C. Wine.
- D. Low-fat yogurt.
- E. Beef broth.
- F. Potatoes.
Correct Answer: A,B,E
Rationale: High-purine foods like liver (A), sardines (B), and beef broth (E) should be limited to reduce gout flare-ups. Wine (C), low-fat yogurt (D), and potatoes (F) are low in purines and generally safe.
The nurse is working on a discharge teaching plan for a client prescribed phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI drug). The nurse knows teaching was successful if the client states,
- A. I will not be able to have wine and aged cheese anymore.'
- B. I should avoid all dairy products from now on.'
- C. Taking this medication with vitamin K-containing foods is dangerous.'
- D. I will need to decrease my dietary fiber now.'
Correct Answer: A
Rationale: MAOIs like phenelzine require avoiding tyramine-rich foods (e.g., wine, aged cheese) to prevent hypertensive crisis. Dairy, vitamin K, and fiber are not contraindicated.