Nokea
The healthcare provider has prescribed silver sulfadiazine (Silvadene) for the client with a partial-thickness burn, which has cultured positive for gram-negative bacteria. The nurse is reinforcing information to the client about the medication. Which statement made by the client indicates a lack of understanding about the treatment?
- A. The medication is an antibacterial.
- B. The medication will help heal the burn.
- C. The medication will permanently stain my skin.
- D. The medication should be applied directly to the wound.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, 'My chest still hurts.' Select the appropriate actions that the nurse should take.
- A. Call a code blue.
- B. Contact the registered nurse.
- C. Contact the client's family.
- D. Assess the client's pain level.
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to contact the registered nurse. When a client with coronary artery disease experiences chest pain and does not achieve relief after the initial administration of nitroglycerin, it is crucial to inform the registered nurse promptly. Following the usual guideline for nitroglycerin administration, the nurse may administer a second tablet after assessing the client's pain level. The nurse should continue to assess the client's pain and monitor vital signs before each dose administration. Calling a code blue is not warranted at this point, as the client's condition does not indicate an immediate life-threatening emergency. Contacting the client's family is not necessary unless requested by the client.
A client with a history of chronic heart failure is prescribed spironolactone (Aldactone). Which of the following statements indicates that the client understands the medication teaching?
- A. I will avoid potassium-rich foods.
- B. I will not use a salt substitute.
- C. I will monitor my weight daily.
- D. I will increase my fluid intake as prescribed.
Correct Answer: A
Rationale: The correct statement is 'I will avoid potassium-rich foods.' Spironolactone (Aldactone) is a potassium-sparing diuretic, which can lead to hyperkalemia if potassium intake is not regulated. Therefore, avoiding potassium-rich foods is crucial to prevent this complication. Using a salt substitute can also increase potassium levels. Monitoring weight daily is essential in heart failure management, but it is not specific to spironolactone. Increasing fluid intake as prescribed is generally recommended for heart failure management but is not directly related to spironolactone use.
A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which information should the nurse teach when carrying out plans for discharge?
- A. Keep insulin vials refrigerated at all times.
- B. Rotate the insulin injection sites systematically.
- C. Increase the amount of insulin before unusual exercise.
- D. Monitor the urine acetone level to determine the insulin dosage.
Correct Answer: B
Rationale: When a client is stabilized with daily insulin injections, it is crucial to rotate the injection sites systematically. This practice helps prevent the development of lipodystrophy, which can affect insulin absorption and lead to inconsistent glucose control. Additionally, rotating sites minimizes discomfort and tissue damage, ensuring optimal insulin delivery and effectiveness.
Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. Which of the following would the nurse include in the client-teaching plan regarding this medication?
- A. To take the medication after meals
- B. To return to the clinic weekly for serum drug-level testing
- C. To call the health care provider (HCP) if a skin rash occurs
- D. To restrict alcohol intake with this medication
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Mycophenolate mofetil (CellCept) is prescribed for a client as prophylaxis for organ rejection following an allogeneic renal transplant. Which of the following instructions does the nurse reinforce regarding administration of this medication?
- A. Administer on an empty stomach.
- B. Take the medication with a calcium-type antacid.
- C. Open the capsule and mix with food for administration.
- D. Contact the health care provider (HCP) if a sore throat occurs.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.