Nokea
The client taking allopurinol (Zyloprim) should be taught to:
- A. Drink approximately eight glasses of water per day.
- B. Avoid the intake of fruits.
- C. Allow 6 weeks for the drug to work.
- D. Eat foods containing purine.
Correct Answer: A
Rationale: Allopurinol prevents uric acid buildup, and adequate hydration (eight glasses of water) reduces kidney stone risk. Fruits are not restricted, the drug works sooner, and purine foods should be limited.
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A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include
- A. explaining that the client will be walking with a prosthesis soon after surgery.
- B. encouraging the client to share his feelings and fears about the surgery.
- C. taking the informed consent form to the client and asking him to sign it.
- D. evaluating how the client plans to maintain his schoolwork during hospitalization.
Correct Answer: B
Rationale: discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning
The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
- A. Identity versus identity diffusion.
- B. Intimacy versus isolation.
- C. Integrity versus despair and disgust.
- D. Industry versus inferiority.
Correct Answer: B
Rationale: is the stage for 19- to 35-year-olds
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
- A. Risk for dehydration
- B. Ineffective airway clearance
- C. Altered nutrition
- D. Risk for injury
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?
- A. Monitor for hyperkalemia
- B. Place in protective isolation
- C. Precautions with position changes
- D. Administer diuretics as ordered
Correct Answer: C
Rationale: Precautions with position changes. Multiple myeloma causes osteoporosis, increasing the risk of pathological fractures, necessitating careful positioning.
The nurse is caring for a 78-year-old woman in a long-term care facility. The client is sitting in a geriatric chair with the attached tray in place. The client is agitated and appears to be sliding down in the chair. What is the best action for the nurse to take?
- A. Ask the supervisor for advice
- B. Put a jacket restraint on the client
- C. Tie a sheet around the client's waist
- D. Use foam wedges beside the client
Correct Answer: D
Rationale: Foam wedges stabilize the client safely and comfortably, preventing sliding without restrictive measures. Restraints (jacket or sheet) increase agitation and risk, and consulting the supervisor delays action.