Nokea
The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply.
- A. Avoid annual influenza vaccination
- B. Avoid situations that cause physical and emotional stress
- C. Avoid sun exposure and ultraviolet light when possible
- D. Notify the health care provider if you have fever
- E. Use antibiotic soap to cleanse skin rashes
Correct Answer: B,C,D
Rationale: Stress, sun exposure, and infections can exacerbate lupus. Influenza vaccination is recommended, and antibiotic soap is unnecessary.
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A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering
- A. pulmonary embolectomy
- B. vena caval interruption
- C. increasing the Coumadin therapy to an INR of 3-4
- D. thrombolytic therapy
Correct Answer: B
Rationale: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.
A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?
- A. Elbow
- B. Mummy
- C. Jacket
- D. Clove hitch
Correct Answer: A
Rationale: Elbow. The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.
The nurse is caring for a client with chronic venous insufficiency. Which of the following findings would be consistent with the condition?
- A. absent pedal pulses bilaterally
- B. toes cold to palpation bilaterally
- C. absence of hair on the lower extremities
- D. brown, hardened skin on the lower extremities
Correct Answer: D
Rationale: Brown, hardened skin (lipodermatosclerosis) is characteristic of chronic venous insufficiency due to hemosiderin deposition and fibrosis.
The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.
- A. Client with iron deficiency anemia takes iron supplements with milk
- B. Client takes levothyroxine early in the morning on an empty stomach
- C. Client taking phenazopyridine for urine infection states that the urine has turned orange
- D. Client taking metronidazole mentions going to a wine-tasting party tonight
- E. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold
Correct Answer: A,D,E
Rationale: Milk reduces iron absorption, metronidazole with alcohol can cause severe reactions, and diphenhydramine can worsen closed-angle glaucoma.
Which of the following indicates failure of a ventriculoperitoneal shunt?
- A. Projectile vomiting
- B. Abdominal distention
- C. Decreased urinary output
- D. Hemodilution
Correct Answer: A
Rationale: Projectile vomiting is a sign of increased intracranial pressure due to ventriculoperitoneal shunt failure, indicating obstruction or malfunction.