Nokea
The nurse is caring for a child with celiac disease. The nurse's discharge teaching plan should include:
- A. Dietary instructions and a list of foods to be avoided
- B. Hand-washing instructions to prevent disease transmission
- C. Instructions to continue antibiotics for 1 week
- D. Explaining that one attack confers immunity
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet, so dietary instructions and a list of foods to avoid are essential, making A correct. Hand-washing , antibiotics , and immunity are not relevant to celiac disease management.
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A 56-year-old woman is receiving digoxin (Lanoxin) 0.25 mg PO qd and furosemide (Lasix) 40 mg PO bid. She calls her physician for complaints of mild diarrhea. The physician prescribes Kaopectate 60 mg after each bowel movement for 2 days and instructs her to call back if symptoms don't subside.
The nurse should instruct the woman to
- A. make no changes in her medication schedule.
- B. wait 1 hour before taking her scheduled medications if she takes the Kaopectate.
- C. hold her scheduled medications until the diarrhea subsides.
- D. take the Lanoxin but hold the Lasix if she takes the Kaopectate.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) PO meds would be absorbed by Kaopectate not by stomach (2) correct-Kaopectate absorbs PO meds, separate administration of other meds (3) other meds should be given later (4) both meds should be given later
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I brush my teeth twice a day.
- B. I take my medication with milk.
- C. I have a rash on my arms.
- D. I feel drowsy in the morning.
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.
The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should
- A. Irrigate it as ordered with distilled water
- B. Irrigate it as ordered with normal saline
- C. Check for kinking or obstruction
- D. Withdraw the tube several inches and reposition it
Correct Answer: B
Rationale: Irrigate it as ordered with normal saline. Nasogastric tubes are only irrigated with normal saline to maintain patency.
A client one day after a thoracotomy.
Nursing actions on the care plan include: turn, cough, and deep breathe q2h. The nurse understands that the purpose of this nursing action is to
- A. promote ventilation and prevent respiratory acidosis.
- B. increase oxygenation and removal of secretions.
- C. increase pH and facilitate balance of bicarbonate.
- D. prevent respiratory alkalosis by increasing oxygenation.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure
A client is scheduled for a traditional abdominal cholecystectomy.
Which of the following statements, if made by the nurse to the client the night before surgery, is MOST important?
- A. It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet.'
- B. Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times.'
- C. There will be a machine available to you after surgery for you to use to continuously receive pain medication.'
- D. You may come back from surgery with a tube in your nose that drains your gall bladder.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each implementation. Is it desired? (1) not most important initially, teaching should be done before discharge (2) correct-should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring (3) PCA pumps used postoperative but medication is administered intermittently (4) NG tube used to drain stomach, T-tube used to drain common bile duct