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A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
- A. Latex
- B. Seafood
- C. Bee stings
- D. Peanuts
Correct Answer: A
Rationale: Correct Answer: A (Latex)
Rationale: Latex allergies can lead to severe reactions, including anaphylaxis, if the client comes into contact with latex during IV therapy. It is crucial to inform the charge nurse to ensure alternative materials are used to prevent a life-threatening allergic reaction.
Summary of other choices:
B: Seafood - While seafood allergies are common, they are not directly related to IV therapy unless the IV solution contains seafood-derived components.
C: Bee stings - Bee sting allergies are important but are not directly relevant to IV therapy unless there is a risk of exposure during the procedure.
D: Peanuts - Peanut allergies are significant but do not pose a direct threat during IV therapy unless peanuts are present in the IV solution or equipment.
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A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming.
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is essential for proper foot care in diabetes mellitus as it helps prevent fungal infections and keeps feet dry. Soaking feet twice daily (choice A) can lead to skin breakdown. Rounding the edges of toenails (choice B) can increase the risk of ingrown toenails. Using moisturizing lotion between the toes (choice C) can create a moist environment, fostering fungal growth. Therefore, wearing clean cotton socks daily is the most appropriate instruction to promote foot health in a client with diabetes mellitus.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A non-coring needle
Correct Answer: D
Rationale: The correct answer is D: A non-coring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes the risk of coring (removal of a piece of the septum) which can lead to complications. Using an angiocatheter (choice A) or a butterfly needle (choice C) can increase the risk of coring, causing damage to the port. A 25-gauge needle (choice B) is too small for accessing the port effectively. In summary, the non-coring needle is the optimal choice for accessing the port safely and effectively, while the other options pose risks of coring or inefficiency.
A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. Range-of-motion exercises help prevent immobility-related complications such as blood clots and promote circulation postoperatively. This helps prevent complications like deep vein thrombosis. Choices A, C, and D are incorrect. Remaining on bed rest for 24 hours can increase the risk of blood clots. Using an incentive spirometer every 4 hours helps with lung function, not circulation. Placing a pillow under the knees only helps with comfort, not circulation.
A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?
- A. Do you receive Holy Communion?
- B. Do you follow a kosher diet?
- C. Do you consume pork products?
- D. Do you oppose receiving a blood transfusion if necessary?
Correct Answer: C
Rationale: The correct answer is C: Do you consume pork products? This question is relevant for a client practicing Islam as pork consumption is prohibited in Islam. Asking about pork consumption helps the nurse understand and respect the client's religious beliefs.
Incorrect answers:
A: Do you receive Holy Communion? - This question is related to Christian practices, not Islam.
B: Do you follow a kosher diet? - This question is related to Jewish dietary laws, not specific to Islam.
D: Do you oppose receiving a blood transfusion if necessary? - While some religious beliefs may affect views on blood transfusions, this question does not specifically address Islamic beliefs.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. This is the correct action as it validates the client's feelings and provides reassurance that anger is a common emotion when dealing with a cancer diagnosis. By acknowledging the client's emotions, the nurse can build trust and support the client through the grieving process.
A: Discussing risk factors is not the priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage.
C: Providing written information about loss and grief phases may not address the client's current emotional state.
In summary, option D is the best choice as it acknowledges the client's feelings and offers support during a difficult time.