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Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
- A. Report any changes in hearing immediately because this is a common side effect.
- B. You should be taking vitamin B6 to prevent painful neuritis.
- C. If your big toes become painful, you must tell the physician.
- D. Your perspiration and urine may turn red-orange.
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.
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The nurse is assigned to work with the parents of a retarded child.
- A. What should the nurse include in the care plan for the parents of a retarded child?
- B. Interpret the grieving process for the parents.
- C. Discuss the reality of institutional placement.
- D. Assist the parents in making decisions and long-term plans for the child.
- E. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: A family assessment is essential to understand the parents’ grieving, coping, and support needs, guiding tailored interventions. Interpreting grief, discussing placement, or assisting with plans are premature without first assessing the family’s situation.
The nurse is caring for a client with a history of pancreatitis.
- A. Which dietary instruction is most appropriate for a client with chronic pancreatitis?
- B. High-fat, low-protein diet.
- C. Low-fat, high-protein diet.
- D. High-carbohydrate, low-fat diet.
- E. Low-carbohydrate, high-fat diet.
Correct Answer: B
Rationale: A low-fat, high-protein diet reduces pancreatic stimulation and supports tissue repair in chronic pancreatitis. High-fat diets exacerbate symptoms, and carbohydrate balance is less critical.
The LPN/LVN is to perform a sterile procedure. Which action will maintain a sterile field?
- A. Keeping the sterile field within the line of vision
- B. Opening sterile packages with sterile gloves
- C. Talking to others over the sterile field
- D. Handing the physician medicine over the sterile field
Correct Answer: A
Rationale: Keeping the sterile field in view ensures no contamination occurs, maintaining sterility during the procedure.
The nurse has just returned to the desk and has four phone messages to return.
- A. Which phone message should the nurse return first?
- B. A woman in her first trimester of pregnancy complaining of heartburn.
- C. A man complaining of heartburn that radiates to his jaw.
- D. A woman complaining of hot flashes and difficulty sleeping.
- E. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: Heartburn radiating to the jaw in a man indicates possible chest pain, which could be a symptom of a myocardial infarction, a life-threatening condition requiring immediate medical attention. The other conditions (pregnancy-related heartburn, menopausal symptoms, and knee pain) are less urgent and can be addressed after ruling out a cardiac emergency.
The client asks the nurse how the health care provider could tell she was pregnant 'just by looking inside.' What is the best explanation by the nurse?
- A. Bluish coloration of the cervix and vaginal walls
- B. Pronounced softening of the cervix
- C. Clot of very thick mucous that obstructs the cervical canal
- D. Slight rotation of the uterus to the right
Correct Answer: A
Rationale: Chadwick's sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.