Nokea
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. \| can continue to take St John's wort while taking this medication
- B. I know It will be& couple of weeks before the medication helps me feel better
- C. I expect this medication to raise my blood pressure
- D. I should take this medication on an empty stomach
Correct Answer: B
Rationale: Correct Answer: B: "I know It will be a couple of weeks before the medication helps me feel better"
Rationale: Amitriptyline is a tricyclic antidepressant that can take several weeks to reach its full therapeutic effect. This statement shows the client understands the delayed onset of action of the medication, managing expectations. This is crucial in ensuring the client does not become discouraged if they do not feel immediate improvement.
Incorrect Choices:
A: "I can continue to take St John's wort while taking this medication" - St John's wort can interact with amitriptyline, leading to increased side effects and reduced effectiveness.
C: "I expect this medication to raise my blood pressure" - Amitriptyline can indeed cause hypotension, not hypertension.
D: "I should take this medication on an empty stomach" - Amitriptyline should be taken with food to reduce gastrointestinal side effects and improve absorption.
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A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine
- B. How to secure the tracheostomy tube with ties at the back of the neck
- C. How to change the nondisposable tracheostomy tube daily
- D. How to change the tracheostomy dressing using clean technique
Correct Answer:
Rationale: Correct Answer: B. How to secure the tracheostomy tube with ties at the back of the neck.
Rationale: Securing the tracheostomy tube with ties is crucial to prevent accidental dislodgement and ensure proper placement for oxygenation. This step helps maintain the airway and prevents complications. Teaching this ensures safety and proper care for the client.
Incorrect Choices:
A: Operating the portable suction machine is important but not the priority for discharge teaching.
C: Changing the nondisposable tracheostomy tube daily is not recommended as it can increase the risk of infection.
D: Changing the tracheostomy dressing using clean technique is essential, but securing the tube takes precedence in discharge teaching.
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.
- A. Change the indwelling urinary catheter tubing every 3 days
- B. Empty the drainage bag when it is half-full
- C. Place the drainage bag on the bed when transporting the client.
- D. Use soap and water to provide perineal care
- E. Review the need for the indwelling urinary catheter daily.
- F. Encourage the client to drink 3000 mL of fluid daily
Correct Answer: D,E
Rationale: Proper hygiene and regular assessment of catheter necessity reduce UTI risks.
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following activities should the nurse perform first?
- A. Administer an antiemetic medication.
- B. Evaluate functioning of the suction device.
- C. Provide oral hygiene care
- D. Replace the NG tube.
Correct Answer: B
Rationale: The correct answer is B: Evaluate functioning of the suction device. First, the nurse needs to ensure proper suction to prevent aspiration and maintain airway patency. This step is crucial for the client's safety and well-being. Administering an antiemetic medication (A) may be necessary but not the first priority. Providing oral hygiene care (C) can wait until after ensuring proper suction. Replacing the NG tube (D) is not necessary unless there are signs of tube malfunction.
Which of the following actions should the nurse include in the plan of care?
- A. Give cromolyn nebulized solution every 8 hr
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Apply a warm compress to the operative site once daily
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B because administering analgesics on a scheduled basis for the first 24 hours post-surgery helps manage pain effectively. Pain management is crucial for patient comfort and promotes early mobilization. Choice A is incorrect because cromolyn nebulized solution is not typically used post-operatively. Choice C is incorrect as applying a warm compress once daily may not provide adequate pain relief. Choice D is incorrect as clear liquids are usually started slowly to prevent nausea and vomiting, not 6 hours post-surgery.
The client is at risk for developing-----due to---
- A. mania
- B. serotonin syndrome
- C. psychosis
- D. feelings of hopelessness
- E. adverse effects of paroxetine
- F. anxiety
Correct Answer: B,E
Rationale: Increasing paroxetine while discontinuing fluoxetine can lead to serotonin syndrome.