Nokea
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
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A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to
- A. provide an avenue for nutrients to flow past an obstructed area.
- B. prevent fluid and gas accumulation in the stomach.
- C. administer drugs that can be absorbed directly from the inTest inal mucosa.
- D. remove fluid and gas from the small inTest ine.
Correct Answer: D
Rationale: Miller-Abbott tube provides for inTest inal decompression; inTest inal tube is often used for treatment of paralytic ileus
Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that
- A. AGN is a streptococcal infection that involves the kidney tubules
- B. The disease is easily transmissible in schools and camps
- C. The illness is usually associated with chronic respiratory infections
- D. It is not 'caught' but is a response to a previous B-hemolytic strep infection
Correct Answer: D
Rationale: It is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior.
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
- A. Orange juice, baked chicken, and a cucumber and tomato salad
- B. Milk, roast beef, and spinach salad
- C. Iced tea, fish sandwich, and mixed vegetables
- D. Cola, fried shrimp, and coleslaw
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
The client taking allopurinol (Zyloprim) should be taught to:
- A. Drink approximately eight glasses of water per day.
- B. Avoid the intake of fruits.
- C. Allow 6 weeks for the drug to work.
- D. Eat foods containing purine.
Correct Answer: A
Rationale: Allopurinol prevents uric acid buildup, and adequate hydration (eight glasses of water) reduces kidney stone risk. Fruits are not restricted, the drug works sooner, and purine foods should be limited.