Nokea
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
- A. We will call the health care provider if the child develops acne.'
- B. Our child should brush and floss carefully after every meal.'
- C. We will skip the next dose if vomiting or fever occur.'
- D. When our child is seizure-free for 6 months, we can stop the medication.'
Correct Answer: B
Rationale: Our child should brush and floss carefully after every meal.' Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.
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The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
The HCP documents that the client has a generalized infection. Which specific assessment finding should the nurse expect?
- A. Redness and warmth at the site
- B. Swelling and pain at the site
- C. Hypertension and bradycardia
- D. Fever and widespread muscle aches
Correct Answer: D
Rationale: D: Generalized infections cause systemic symptoms like fever and muscle aches. A, B: These are localized signs. C: Hypotension and tachycardia are more likely.
A client with heart failure has a prescription for Digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication
- A. can predispose to dysrhythmias
- B. may lead to oliguria
- C. may cause irritability and anxiety
- D. sometimes alters consciousness
Correct Answer: A
Rationale: can predispose to dysrhythmias. The nurse should be aware of a decrease in the client's potassium levels because low potassium enhances the effects of Digoxin and predisposes the client to dysrhythmias. The other options are seen in hyperkalemia. Muscle weakness occurs in both hyperkalemia and hypokalemia.
The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply.
- A. Offering the client sterile disposable tissues
- B. Wearing a mask while examining the client
- C. Offering the client water to drink while waiting
- D. Teaching how to cover the mouth when coughing
- E. Performing hand hygiene before and after client contact
- F. Separating the client by at least 3 feet from others in the area
Correct Answer: B,D,E,F
Rationale: B: A mask is required during examination to prevent droplet transmission. D: Teaching cough etiquette reduces spread. E: Hand hygiene prevents pathogen transmission. F: Maintaining 3 feet distance reduces droplet spread. A: Sterile tissues are unnecessary. C: Water does not limit transmission.
The client who is receiving TPN through a subclavian triple-lumen catheter expresses concern to the nurse about bacteria entering the blood through the catheter. The nurse explains that the risk of catheter-related infections can be decreased by taking which action?
- A. Applying an antibiotic ointment at the catheter insertion site daily
- B. Changing the dressing over the catheter insertion site every day
- C. Designating one port of the catheter exclusively for the TPN solution
- D. Instilling an antibiotic solution daily into each port of the catheter
Correct Answer: C
Rationale: C: Using one port exclusively for TPN reduces infection risk by limiting access points. A, D: Antibiotic use risks resistance. B: Daily dressing changes are unnecessary unless soiled.