Nokea
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Maintaining seizure precautions
- B. Restricting fluid intake
- C. Increasing sensory stimuli
- D. Applying ankle and wrist restraints
Correct Answer: A
Rationale: These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. Fluid intake should be increased to prevent dehydration. Environmental stimuli should be decreased to prevent precipitation of seizures. Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
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A client with a history of seizure disorder is admitted with complaints of breakthrough seizures. The nurse should give priority to:
- A. Administering anticonvulsants
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring respiratory rate
Correct Answer: A
Rationale: Administering anticonvulsants is the priority to control breakthrough seizures and prevent status epilepticus.
The nurse is caring for a client with a brain tumor who has been prescribed levofloxacin (Levaquin) for a sinus infection. What specific instructions should be included when educating the client regarding taking this drug?
- A. Avoid direct sunlight.
- B. Report unexplained joint pain.
- C. No antacids should be taken within 2 hours of taking the drug.
- D. Take the medication on an empty stomach.
- E. Keep the head of the bed elevated for 30 minutes after taking.
Correct Answer: A, B, C
Rationale: Levofloxacin requires avoiding sunlight (A) due to photosensitivity, reporting joint pain (B) for tendonitis risk, and avoiding antacids (C) to ensure absorption. Empty stomach (D) is optional, and bed elevation (E) is unrelated.
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
- A. Putting all joints through full range-of-motion twice daily
- B. Massaging the joints briskly with lotion or liniment after bath
- C. Immobilizing the joints in functional position using splints, rolls, and pillows
- D. Applying warm water bottle or heating pads over involved joints
Correct Answer: C
Rationale: Any movement of the joint causes severe pain. Touching or moving the joint causes severe pain. Immobilization in a functional position allows the joint to rest and heal. Pressure from the warm water bottle or pads can cause severe pain or burning of the skin.
The doctor has ordered Ampicillin 100 mg every six hours IV push for an infant weighing 7 kg. The suggested dose for infants is 25-50 mg/kg/day in equally divided doses. The nurse should:
- A. Give the medication as ordered.
- B. Give half the amount ordered.
- C. Give the ordered amount q 12 hrs.
- D. Check the order with the doctor.
Correct Answer: D
Rationale: The ordered dose (100 mg q6h = 400 mg/day) for a 7 kg infant is 57.14 mg/kg/day, exceeding the recommended 25-50 mg/kg/day. The nurse should verify the order to prevent overdose.
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Pork chop, baked acorn squash, brussel sprouts
- B. Chicken breast, rice, and green beans
- C. Roast beef, baked potato, and diced carrots
- D. Tuna casserole, noodles, and spinach
Correct Answer: A
Rationale: Acorn squash and brussels sprouts are potassium-rich, indicating successful teaching. The other options contain fewer potassium-rich foods.