Nokea
The client is receiving discharge teaching for a new prescription of phenelzine. The nurse should instruct the client that it is not safe to eat which of the following foods while taking this medication?
- A. whole grain bread
- B. Avocados
- C. Smoked salmon
- D. Pepperoni pizza
Correct Answer: B
Rationale: Avocados contain high levels of tyramine, which can cause a hypertensive crisis when consumed with phenelzine, a monoamine oxidase inhibitor (MAOI). It is essential for clients taking MAOIs to avoid foods rich in tyramine to prevent dangerous interactions and potential health risks.
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A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?
- A. Antibiotic
- B. Beta-blocker
- C. Antiviral
- D. Beta2 agonist
Correct Answer: D
Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.
A client has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
- A. Teach the client to scan the right to see objects on the right side of their body.
- B. Place the bedside table on the right side of the bed.
- C. Orient the client to the food on their plate using the clock method.
- D. Place the wheelchair on the client's left side.
Correct Answer: B
Rationale: In a client with left homonymous hemianopsia, there is a loss of vision on the right side of both eyes. Placing the bedside table on the right side of the bed ensures that essential items are within the client's field of vision, minimizing the risk of injury or accidents. Teaching the client to scan to the right and orienting them using the clock method may be helpful strategies, but placing the bedside table on the right side of the bed is a more direct and immediate intervention to enhance the client's safety and independence.
During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?
- A. Continuous bubbling in the water seal chamber
- B. Gentle constant bubbling in the suction control chamber
- C. Drainage system positioned upright at chest level
- D. Exposed sutures without dressing
Correct Answer: B
Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.
A healthcare professional is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the healthcare professional NOT include in the plan of care?
- A. Have suction equipment available for use
- B. Feed the client thickened liquids
- C. Place food on the unaffected side of the client's mouth
- D. Assign an assistive personnel to feed the client slowly
Correct Answer: D
Rationale: When caring for a client with dysphagia, it is crucial to ensure safe feeding practices. Assigning an assistive personnel to feed the client slowly may not be appropriate as it can increase the risk of aspiration. Thickened liquids, having suction equipment available, and placing food on the unaffected side of the mouth are all appropriate measures to support a client with dysphagia in safe eating and drinking.
A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?
- A. Oxygen equipment
- B. Incentive spirometer
- C. Pulse oximeter
- D. Sterile dressing
Correct Answer: B
Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.