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A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
- A. Orange juice
- B. Grapefruit juice
- C. Milk
- D. Carbonated beverage
Correct Answer: B
Rationale: The correct answer is B: Grapefruit juice. Grapefruit juice can interact with many medications by inhibiting the enzyme that metabolizes the drugs, leading to higher drug levels in the body and potentially causing adverse effects. Orange juice (A), milk (C), and carbonated beverages (D) do not have significant interactions with most medications. It is important for the nurse to advise older adult clients to avoid grapefruit juice to prevent medication interactions and ensure their safety.
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A nurse is preparing to administer digoxin 5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 10
Rationale: The correct answer is 10 tablets. To calculate, you divide the total dose needed (5 mg) by the dose per tablet (0.5 mg). 5 mg ÷ 0.5 mg = 10 tablets. The nurse should administer 10 tablets of digoxin to achieve the desired 5 mg dose. Other choices are incorrect because they do not result in the correct dosage amount required for the client.
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.
A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
- A. I will wear earphones during this test
- B. A small probe is placed inside my ear
- C. A tuning fork is placed on my head
- D. Small electrodes are placed on my scalp
Correct Answer: C
Rationale: The correct answer is C: A tuning fork is placed on my head. In the Rinne test, a tuning fork is first placed against the client's mastoid bone behind the ear and then moved near the ear canal. The client should hear the sound louder when the fork is near the ear if the test is normal. Choice A is incorrect because earphones are not used in the Rinne test. Choice B is incorrect as a probe is not inserted into the ear. Choice D is incorrect as electrodes are not part of the Rinne test. Placing a tuning fork on the head is the correct step in performing the Rinne test to assess hearing conduction.
A nurse is documenting client care including only unexpected findings related to the client's condition. Which of the following documentation methods is the nurse utilizing?
- A. SOAP documentation
- B. Focus charting (DAR)
- C. Charting by exception (CBE)
- D. Problem-oriented medical record (POMR)
Correct Answer: C
Rationale: Charting by exception (CBE) is the correct answer. CBE involves documenting only significant findings or exceptions to the norm. This method focuses on deviations from the expected baseline, promoting efficiency and highlighting important changes in the client's condition. By documenting unexpected findings related to the client's condition, the nurse is using CBE to streamline the documentation process and prioritize critical information. SOAP documentation (A) involves subjective, objective, assessment, and plan format, which is more comprehensive. Focus charting (DAR) (B) focuses on data, action, and response but does not specifically target unexpected findings. Problem-oriented medical record (POMR) (D) emphasizes problem lists, making it less focused on exceptions.