Nokea
The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also allergic to:
- A. All other seafood.
- B. Iodine skin preparations.
- C. Caffeine.
- D. Alcohol-based skin preparations.
Correct Answer: B
Rationale: Shellfish allergies are often associated with iodine sensitivity, as shellfish contain iodine. Iodine-based skin preparations used in surgery could trigger an allergic reaction, so this must be assessed. Other options are unrelated to shellfish allergies.
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A nurse is completing the health history for a client with the patient taking echinacea for a health care. The client asks, 'Why Isn't this helping me feel better?' Which of the following responses by the nurse would be the most accurate?
- A. There is limited information as to the effectiveness of herbal products.
- B. Antibiotics are the agents needed to treat a head cold.
- C. The head cold should be gone within the month.
- D. Combining herbal products with prescription antiviral medications is sure to help you.
Correct Answer: A
Rationale: At this time, there is no strong research evidence to warrant recommendations of herbal products for management of colds; further study is needed to show evidence of therapeutic effects and indications. Antibiotics are effective against bacteria; the head cold may have a viral cause. An uncomplicated upper respiratory tract infection subsides within 2 to 3 weeks. There may be a drug-drug interaction with herbal products and prescriptions.
In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site?
- A. Biliary system.
- B. Gastrointestinal tract.
- C. Brain and meninges.
- D. Pulmonary system.
Correct Answer: A
Rationale: Thrombocytopenia in leukemia increases bleeding risk in the gastrointestinal tract, brain/meninges, and pulmonary system due to mucosal surfaces and vascularity. The biliary system is not a common site for bleeding.
The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes?
- A. Aspirin.
- B. Steroids.
- C. Sulfonylureas.
- D. Angiotensin-converting enzyme (ACE) inhibitors.
Correct Answer: B
Rationale: Steroids can increase blood glucose levels, complicating diabetes management by causing hyperglycemia.
A client with vasospastic disorder (Raynaud's phenomenon) is scheduled for sympathectomy. This surgery is performed:
- A. In the early stages of the disease to prevent further circulatory disturbances
- B. When the disease is controlled by medication
- C. When the client is unable to control stress-related vasospasm
- D. When all other treatment alternatives have failed
Correct Answer: D
Rationale: Sympathectomy, which severs sympathetic nerves to reduce vasospasm, is a last-resort treatment for Raynaud's when all other options (medications, lifestyle changes) fail. It is not performed early, when controlled, or solely for stress-related vasospasm.
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (A) and elevation (D) are supportive but secondary. Abdominal massage (B) is not indicated.