Nokea
A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching?
- A. Vitamin A
- B. Vitamin B1
- C. Vitamin C
- D. Vitamin B12
Correct Answer: A
Rationale: The correct answer is Vitamin A. Fat-soluble vitamins essential for patients with pancreatitis include A, D, E, and K, aiding in proper nutrient absorption. Vitamin B1 (Choice B), also known as thiamine, is a water-soluble vitamin and not a fat-soluble one. Vitamin C (Choice C) is another water-soluble vitamin and not a fat-soluble one. Vitamin B12 (Choice D) is also a water-soluble vitamin and not one of the fat-soluble vitamins crucial for patients with pancreatitis.
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A nurse is reinforcing teaching about food choice with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?
- A. I will give my child peanut butter and mashed egg whites.
- B. I will give my child rice cereal and crackers.
- C. I will give my child pureed liver and strained pears.
- D. I will give my child applesauce and green peas.
Correct Answer: A
Rationale: The correct answer is A because peanut butter and egg whites are not recommended for infants under 12 months due to the risk of choking and allergies. Choices B, C, and D are appropriate food choices for an 8-month-old infant. Rice cereal, crackers, pureed liver, strained pears, applesauce, and green peas are all suitable options for introducing solid foods to infants.
A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.
- B. I have been coughing up foul-tasting, brown, thick sputum.
- C. I have been sweating all day.
- D. I feel hot off and on.
Correct Answer: B
Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.
Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?
- A. Urinary incontinence
- B. Constipation
- C. Nystagmus
- D. Occult bleeding
Correct Answer: D
Rationale: The correct answer is D: Occult bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are known to cause gastrointestinal side effects, including occult bleeding. Occult bleeding refers to bleeding in the gastrointestinal tract that may not be visible in the stool, leading to potential complications like anemia. Urinary incontinence (choice A) is not a common side effect of NSAIDs. Constipation (choice B) is also not a typical side effect associated with NSAIDs. Nystagmus (choice C) is an involuntary eye movement and is not a common side effect of NSAIDs. Therefore, the nurse should caution clients about the risk of occult bleeding when using NSAIDs for arthritis pain management.
The nurse is caring for a client with liver cirrhosis. Which of these findings would indicate that the client is experiencing complications of the disease?
- A. Yellowing of the skin and eyes
- B. Presence of spider angiomas on the skin
- C. Ascites and peripheral edema
- D. Clay-colored stools and dark urine
Correct Answer: D
Rationale: Clay-colored stools and dark urine are classic signs of liver dysfunction, indicating bile flow obstruction commonly seen in liver cirrhosis. This finding is a significant complication requiring immediate medical evaluation. Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction but is not specific to complications. Spider angiomas and ascites with peripheral edema are also associated with liver cirrhosis, but they are not indicative of immediate complications as clay-colored stools and dark urine are.
The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to
- A. enhance absorption of the medication
- B. ensure that the entire dose of medication is given
- C. provide more even distribution of the drug
- D. prevent the drug from tissue irritation
Correct Answer: D
Rationale: The correct answer is D. Deep injection helps to prevent tissue irritation caused by iron, which can be damaging to tissues. Option A is incorrect because deep injection does not primarily aim to enhance absorption, but rather to prevent tissue irritation. Option B is incorrect as the route of administration does not determine whether the entire dose is given. Option C is incorrect because the even distribution of the drug is not the main purpose of deep injection in this context.