Nokea
A nurse is reinforcing teaching with a client who is to start therapy with furosemide. The nurse determines that the teaching is effective when the client states he will increase intake of which of the following foods?
- A. Oatmeal
- B. Baked potatoes
- C. Brown rice
- D. Eggs
Correct Answer: B
Rationale: The correct answer is B: Baked potatoes. Furosemide is a loop diuretic that can lead to potassium depletion. Baked potatoes are high in potassium, which can help prevent hypokalemia associated with furosemide therapy. Oatmeal, brown rice, and eggs are not particularly high in potassium and would not be the best choice for increasing potassium intake. By choosing baked potatoes, the client can help maintain adequate potassium levels while on furosemide therapy.
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A nurse is caring for a client who has chronic renal failure and is receiving epoetin alfa. To check for therapeutic effects, the nurse should monitor which of the following client laboratory tests?
- A. Hemoglobin levels
- B. Iron levels
- C. Platelet count
- D. White blood cell count
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin levels. Epoetin alfa stimulates red blood cell production, increasing hemoglobin levels in clients with chronic renal failure who often have anemia. Monitoring hemoglobin levels helps assess the effectiveness of the medication. Iron levels (B) are important for erythropoiesis but not directly affected by epoetin alfa. Platelet count (C) and white blood cell count (D) are not specifically related to the therapeutic effects of epoetin alfa in chronic renal failure.
A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?
- A. The client had a local reaction from a previous immunization
- B. The client reports having diarrhea this morning
- C. The client is at 9 weeks of gestation
- D. The client reports an allergy to penicillin.
Correct Answer: C
Rationale: The correct answer is C: The client is at 9 weeks of gestation. Administering the MMR vaccine during pregnancy is contraindicated due to the theoretical risk of causing harm to the fetus. The live attenuated MMR vaccine should not be given to pregnant women as it may potentially harm the developing fetus. It is crucial to avoid administration during pregnancy to prevent any adverse effects on the unborn child.
Other options are incorrect because:
A: The client had a local reaction from a previous immunization - Local reactions to previous vaccines are not contraindications to receiving the MMR vaccine.
B: The client reports having diarrhea this morning - Diarrhea is not a contraindication for the MMR vaccine.
D: The client reports an allergy to penicillin - Allergy to penicillin is not a contraindication for the MMR vaccine.
A nurse is preparing to administer medications to a client through an enteral feeding tube. Which of the following interventions is appropriate?
- A. Add the medications to the enteral feeding bag.
- B. Check for gastric residual 15 min after administering the medications
- C. Keep the client's head elevated 15° while administering the medications.
- D. Flush the tube with 30 ml of water between each medication
Correct Answer: D
Rationale: The correct answer is D: Flush the tube with 30 ml of water between each medication. Flushing the tube with water between medications helps prevent clogging and ensures proper medication administration. It also helps prevent interactions between different medications. Adding medications to the feeding bag (choice A) may cause drug interactions or alter the efficacy of the medications. Checking for gastric residual 15 min after administering medications (choice B) is not necessary for enteral tube medication administration. Keeping the client's head elevated 15° (choice C) is important during feeding, but not specifically for medication administration.
A nurse is reinforcing teaching with a client who has angina and a new prescription of nitroglycerin sublingual. Which of the following statements by the client indicates an understanding of the teaching?
- A. If my pain is not relieved in 20 minutes, I will take a second tablet.'
- B. I will keep my tablets on a shelf in the bathroom.'
- C. I should be sure to swallow the tablet whole.'
- D. If my mouth is dry, I will take a sip of water before I take the tablet.'
Correct Answer: D
Rationale: The correct answer is D: "If my mouth is dry, I will take a sip of water before I take the tablet." This statement indicates an understanding of how to properly administer nitroglycerin sublingual. Taking the medication under the tongue allows for faster absorption. Taking a sip of water before taking the tablet helps moisten the mouth and aids in the absorption of the medication. This step is crucial for the effectiveness of nitroglycerin in relieving angina symptoms.
Other choices are incorrect:
A: Taking a second tablet before the 20-minute mark is not recommended as it can lead to an overdose.
B: Keeping tablets in the bathroom exposes them to moisture, affecting their potency.
C: Nitroglycerin sublingual should not be swallowed but dissolved under the tongue for rapid absorption.
A nurse is collecting data from a client who reports nausea and has vomited clear emesis. Which of the following medications should the nurse administer?
- A. Meperidine
- B. Diazepam
- C. Naloxone
- D. Promethazine
Correct Answer: D
Rationale: The correct answer is D: Promethazine. Promethazine is an antiemetic medication commonly used to treat nausea and vomiting. It works by blocking dopamine receptors in the brain, reducing the feeling of nausea. Meperidine (A) is a pain medication and not indicated for nausea. Diazepam (B) is a benzodiazepine used for anxiety and seizures, not for nausea. Naloxone (C) is an opioid antagonist used for opioid overdose, not for nausea.