Nokea
The client who is receiving hydantoin (Dilantin) tells the nurse his urine is pink-colored. What action should the nurse take?
- A. Report this serious side effect immediately to the physician
- B. Reassure the client that this occurs often in persons taking Dilantin
- C. Ask the client if he drank cranberry juice or ate red gelatin recently
- D. Strain the client's urine for possible urinary tract stones
Correct Answer: C
Rationale: Pink urine may result from dietary factors like cranberry juice or red gelatin, which should be ruled out before assuming a Dilantin-related issue.
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A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
An adult has experienced significant vomiting and diarrhea for the past 24 hours. Her chloride level is 90 mEq/L. What would the nurse expect to find when interpreting her sodium level?
- A. It would be high.
- B. It is impossible to predict the sodium level with this information.
- C. It would be low.
- D. It would be normal.
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, likely resulting in a low sodium level, consistent with a low chloride level.
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.
An infant is suspected of having coarctation of the aorta. Which assessment finding is most related to coarctation of the aorta?
- A. Respirations are 70 per minute.
- B. Blood pressure is higher in the upper extremities than in the lower extremities.
- C. There is a heart murmur.
- D. Heart rate is 150 beats per minute.
Correct Answer: B
Rationale: Coarctation of the aorta causes aortic narrowing, leading to higher blood pressure in the upper extremities compared to the lower, a hallmark sign.
The physician orders naproxen sodium (Anaprox) 250 mg enteric-coated tablets PO bid for a 45-year-old man.
Which response, if made by the client, would indicate that the nurse's teaching about the medication has been effective?
- A. I can join my wife in a glass of wine with our dinner when we eat in a restaurant.'
- B. I should avoid milk and dairy products when I take this pill.'
- C. I should call my doctor if my stools turn very dark.'
- D. I don't like to take pills so I will crush the pill and add it to some applesauce.'
Correct Answer: C
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a true statement. (1) alcohol increases risk of GI bleeding (2) should be taken with food, milk, or antacid to decrease GI upset (3) correct-NSAIDS can cause GI bleeding (4) enteric-coated tablet should not be broken