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A nurse is assisting a healthcare provider with a sterile procedure and is preparing to pour solution onto a sterile piece of gauze. In what sequence should the nurse perform the following steps when pouring the sterile solution? In what sequence should the nurse pour sterile solution?
- A. Pick up the bottle with the label facing the palm.
- B. Pour the solution onto the gauze.
- C. Pour 1 to 2 mL into a receptacle.
- D. Perform hand hygiene.
- E. Place the bottle cap face-up on a clean surface.
- F. Remove the bottle cap.
Correct Answer: D,A,F,C,E,B
Rationale: The correct sequence is D, A, F, C, E, B.
1. Perform hand hygiene to ensure cleanliness.
2. Pick up the bottle with the label facing the palm to maintain sterility.
3. Remove the bottle cap to prepare for pouring.
4. Pour 1 to 2 mL into a receptacle to ensure proper amount.
5. Place the bottle cap face-up on a clean surface to prevent contamination.
6. Pour the solution onto the gauze for the sterile procedure to be completed.
Incorrect choices:
- G: It is not a step in the process of pouring sterile solution.
- The correct order ensures sterility, proper amount, and prevention of contamination.
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A nurse is providing dietary education for a patient who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which items in the patient's sample lunch menu would require intervention by the nurse? Which lunch menu item requires intervention for MAOI?
- A. Celery sticks
- B. Sliced apples
- C. Bologna sandwich
- D. Glass of whole milk
Correct Answer: C
Rationale: The correct answer is C: Bologna sandwich. MAOIs interact with tyramine, which can lead to a hypertensive crisis. Bologna is a high-tyramine food that can cause this reaction. Celery, apples, and milk are low in tyramine and safe to consume with MAOIs. Therefore, the bologna sandwich requires intervention to prevent potential adverse effects.
A nurse is caring for a patient who has a new prescription for atorvastatin. Which of the following instructions should the nurse include? What instructions should the nurse include for atorvastatin?
- A. Take the medication in the morning.
- B. Report muscle pain or weakness.
- C. Avoid foods high in vitamin K.
- D. Take the medication with grapefruit juice.
Correct Answer: B
Rationale: The correct answer is B: Report muscle pain or weakness. This is crucial because atorvastatin, a statin medication, can cause muscle-related side effects like myopathy or rhabdomyolysis. By instructing the patient to report muscle pain or weakness, the nurse can monitor for these serious adverse effects and take appropriate actions if needed.
A: Taking the medication in the morning is not specific to atorvastatin and can be taken at any time.
C: Avoiding foods high in vitamin K is not relevant to atorvastatin, as it does not interact with vitamin K.
D: Taking the medication with grapefruit juice is not recommended with atorvastatin as grapefruit juice can interact with certain medications, but not specifically with atorvastatin.
A nurse is caring for a patient and notices that the patient's urine is dark amber, cloudy, and has an unpleasant odor. Which of the following conditions should the nurse associate these findings with? Which condition is associated with dark, cloudy, odorous urine?
- A. Urinary retention
- B. Urinary incontinence
- C. Urinary tract infection
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Urinary tract infection (UTI). Dark amber, cloudy, and odorous urine are common indicators of a UTI. The dark amber color may suggest the presence of blood or concentrated urine due to the infection. Cloudiness can result from the presence of bacteria, white blood cells, or other particles in the urine. The unpleasant odor is often caused by the presence of bacteria breaking down waste products in the urine. Urinary retention (A) usually presents with difficulty emptying the bladder, not changes in urine appearance. Urinary incontinence (B) refers to involuntary leakage of urine and is not typically associated with changes in urine characteristics. Urinary frequency (D) involves frequent urination but does not necessarily cause changes in urine appearance.
A nurse is admitting a patient exhibiting manic behavior. The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse's priority action? What is the priority action for a manic patient?
- A. Encourage self-care.
- B. Assist the patient in identifying coping behaviors.
- C. Prevent self-directed violence.
- D. Identify support systems.
Correct Answer: C
Rationale: The correct answer is C: Prevent self-directed violence. When dealing with a manic patient, the priority action should always be to ensure the safety of the patient and others. Manic episodes can lead to impulsive and risky behaviors, including self-harm or suicide attempts. By prioritizing the prevention of self-directed violence, the nurse can address the immediate threat to the patient's well-being. Encouraging self-care (choice A) and identifying coping behaviors (choice B) are important aspects of care but may not be the most urgent in this situation. Identifying support systems (choice D) is also valuable but does not address the immediate safety concerns presented by the manic behavior.
A nurse is caring for a patient who has a new prescription for lisinopril. Which of the following laboratory values should the nurse monitor? Which lab value should the nurse monitor for lisinopril?
- A. Serum potassium
- B. Serum calcium
- C. Serum magnesium
- D. Serum chloride
Correct Answer: A
Rationale: The nurse should monitor serum potassium levels because lisinopril, an ACE inhibitor, can cause potassium retention leading to hyperkalemia. Hyperkalemia can result in serious cardiac complications. Monitoring potassium levels allows timely intervention if levels become elevated. Serum calcium, magnesium, and chloride are not typically affected by lisinopril, making choices B, C, and D incorrect. The correct answer, A, is crucial for patient safety and reflects the physiological impact of lisinopril on potassium levels.