Nokea
If the client complains of GI side effects associated with rifampin (Rifadin), which nursing action is best?
- A. Administering the drug at night
- B. Giving the drug with food or at mealtimes
- C. Encouraging the client to drink plenty of water
- D. Providing the client with an antacid
Correct Answer: B
Rationale: Giving rifampin with food can reduce gastrointestinal side effects, such as nausea, without compromising its efficacy.
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Which option below is considered a positive Homan's Sign for the assessment of a deep vein thrombosis (DVT)?
- A. The patient reports pain when the foot is manually dorsiflexed.
- B. The patient reports pain when the foot is manually plantarflexed.
- C. The patient experiences pain when the leg is extended.
- D. the patient experiences pain when the leg is flexed.
Correct Answer: A
Rationale: Homan's Sign is NOT reliable because of false positives, but know for exams how to elicit a response. It done by manually (forced) dorsiflexing the patient's foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan's Sign. However, the MD must further investigate if the patient has a DVT.
Which discharge instruction is most appropriate for reducing the client's fatigue and shortness of breath during mealtimes?
- A. Eat simple carbohydrates for quick energy.
- B. Eat fatty foods to get maximum caloric intake.
- C. Eat frequent, small meals to reduce energy use.
- D. Eat the largest meal late at night before sleep.
Correct Answer: C
Rationale: Frequent, small meals reduce the energy required for digestion, minimizing fatigue and shortness of breath in COPD clients.
The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first?
- A. Administer the narcotic analgesic intravenous push (IVP).
- B. Perform gentle oral hygiene.
- C. Place the client in semi-Fowler's position.
- D. Assess the client's pain.
Correct Answer: D
Rationale: Pain assessment (D) is the first step to determine severity and guide treatment. Narcotics (A), oral hygiene (B), and positioning (C) follow based on assessment.
The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine?
- A. The client diagnosed with congestive heart failure.
- B. The client with a documented allergy to eggs.
- C. The client who has had an anaphylactic reaction to penicillin.
- D. The client who has an elevated blood pressure and pulse.
Correct Answer: B
Rationale: Influenza vaccines are often grown in eggs, making egg allergy (B) a contraindication due to anaphylaxis risk. Congestive heart failure (A), penicillin allergy (C), and elevated vitals (D) are not contraindications for the flu vaccine.
The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, 'What is happening to me? Why did I get this?' Which statement by the nurse is most appropriate?
- A. Most people who almost drown end up developing ARDS.
- B. Platelets and fluid enter the alveoli due to permeability instability.
- C. Your lungs are filling up with fluid, causing breathing problems.
- D. Smoking has caused your lungs to become weakened, so you got ARDS.
Correct Answer: C
Rationale: Fluid-filled lungs (C) explain ARDS simply, addressing breathing issues. Drowning link (A), permeability (B), and smoking (D) are less accurate or overly technical.