Nokea
The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should:
- A. Pour the solution over ice chips.
- B. Mix the solution with an antacid.
- C. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
- D. Disguise the solution in a pureed fruit or vegetable.
Correct Answer: C
Rationale: SSKI has an unpleasant taste and can stain teeth. Diluting it with water, milk, or juice and using a straw minimizes discomfort and staining.
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The nurse is discharging a client who is prescribed antitubercular medications for pulmonary tuberculosis. The nurse is concerned about an adverse reaction to the medications if the client
- A. lives with a roommate and works as a flight attendant.
- B. has an implanted hormonal intrauterine device (IUD).
- C. smokes one pack of cigarettes per day.
- D. drinks three glasses of red wine each day.
Correct Answer: D
Rationale: Alcohol consumption, such as drinking three glasses of red wine daily, increases the risk of hepatotoxicity when taking antitubercular medications like isoniazid and rifampin, which are metabolized by the liver. Choice A is irrelevant to medication reactions, though it may pose a transmission risk. Choice B (IUD) and Choice C (smoking) do not directly interact with antitubercular medications to cause adverse reactions.
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
- A. It must have been eating too many foods with salt in them. Salt pulls water with it.'
- B. The swelling in his ankles must have moved up closer to his heart so the fluid circulates better.'
- C. He must have forgotten to take his daily water pill.'
- D. Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels.'
Correct Answer: D
Rationale: Cirrhosis causes portal hypertension and hypoalbuminemia, leading to ascites (D). Salt intake (A) may worsen but isn't the primary cause. Ankle edema (B) and diuretics (C) are secondary factors.
A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?
- A. Activity intolerance related to fatigue and pain.
- B. Self-care deficit related to increasing joint pain.
- C. Selective coping related to chronic pain.
- D. Disturbed body image related to fatigue and joint pain.
Correct Answer: A
Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.
A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply.
- A. Begin Warfarin (Coumadin).
- B. Check the postoperative CBC, INR, PTT, & platelet levels.
- C. Confirm availability of blood products.
- D. Monitor the mediastinal chest tube drainage.
- E. Start a Dopamine (Intropin) drip for a systolic BP <100.
Correct Answer: B,C,D
Rationale: Checking lab values (B), confirming blood products (C), and monitoring chest tube drainage (D) address bleeding and ensure timely intervention. Warfarin and dopamine are inappropriate for acute bleeding.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
- A. Increase daily fluid intake to at least 2 to 3 L.
- B. Strain urine at home regularly.
- C. Eliminate dairy products from the diet.
- D. Follow measures to alkalinize the urine.
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.