Nokea
A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will keep the medication refrigerated.
- B. I will mix the medication with juice before taking it.
- C. I will stop taking the medication when I feel better.
- D. I will take the medication on an empty stomach.
Correct Answer: A
Rationale: The correct answer is A: "I will keep the medication refrigerated." This is correct because cephalexin oral suspension should be stored in the refrigerator to maintain its potency and stability. Storing it at room temperature may lead to degradation of the medication. Choice B is incorrect as cephalexin should be taken as prescribed, not mixed with juice. Choice C is incorrect as the full course of antibiotics should be completed even if the client feels better. Choice D is incorrect as cephalexin can be taken with or without food.
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A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
- A. The client reports ringing in the ears.
- B. The client is becoming flushed.
- C. The client reports increased thirst.
- D. The client has a decreased urine output.
Correct Answer: B
Rationale: The correct answer is B: The client is becoming flushed. Flushing is a common adverse effect of vancomycin, indicating a possible allergic reaction or infusion reaction. Flushing can be a sign of red man syndrome, a severe reaction to vancomycin. The nurse should monitor closely and report this finding to the healthcare provider.
Incorrect Answer Rationale:
A: The client reports ringing in the ears - this is a potential adverse effect of vancomycin, but not as critical as flushing.
C: The client reports increased thirst - this is not typically associated with vancomycin adverse effects.
D: The client has a decreased urine output - this may indicate nephrotoxicity, a known side effect of vancomycin, but flushing is more indicative of an immediate adverse reaction.
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?
- A. Avoid high-fat cuts of meat.
- B. Increase your intake of fried foods.
- C. Consume dairy products at every meal.
- D. Eat large meals to avoid frequent digestion.
Correct Answer: A
Rationale: The correct answer is A: Avoid high-fat cuts of meat. Cholelithiasis is the formation of gallstones, often related to high-fat diets. High-fat cuts of meat can trigger gallbladder contractions, leading to pain. The rationale is to reduce fat intake to prevent further gallstone formation. Choices B, C, and D are incorrect. B: Increasing fried foods can exacerbate symptoms due to their high-fat content. C: Consuming dairy products at every meal is not recommended as some dairy products can be high in saturated fats. D: Eating large meals can overload the digestive system, potentially leading to gallbladder discomfort.
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Report cloudy dialysate drainage to the provider.
- B. Lower the drainage bag below the level of the abdomen.
- C. Encourage fluid intake of 3L per day.
- D. Use sterile gloves only when removing the catheter.
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
- A. Monitor urine output.
- B. Assess level of consciousness.
- C. Check ABGs.
- D. Monitor for signs of withdrawal.
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (D) is important but not as urgent as assessing respiratory status.
A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?
- A. A client receiving chemotherapy for early-stage breast cancer.
- B. A client whose medications to manage Parkinsons disease are no longer effective.
- C. A client recovering from a total knee replacement.
- D. A client with seasonal allergies needing symptom relief.
Correct Answer: B
Rationale: The correct answer is B because the client with Parkinson's disease whose medications are no longer effective may benefit from the specialized care and symptom management provided by palliative care. Palliative care focuses on improving quality of life for individuals with serious illnesses by addressing physical, emotional, and spiritual needs. Referral is appropriate when symptoms are not adequately controlled. Choices A, C, and D do not require palliative care as they involve routine treatments or procedures that do not necessarily indicate the need for specialized palliative services.