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The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?
- A. Take the medication with or without food.
- B. Report any increase in suicidal thoughts.
- C. Avoid foods high in tyramine.
- D. Expect improvement within 24 hours.
Correct Answer: B
Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.
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Which client is at the highest risk for developing pressure ulcers?
- A. A 50-year-old client with a fractured femur
- B. A 30-year-old client with diabetes mellitus
- C. A 65-year-old client with limited mobility
- D. A 70-year-old client with a history of stroke
Correct Answer: C
Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.
What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter?
- A. Irrigate the catheter daily.
- B. Change the catheter every 72 hours.
- C. Apply antibiotic ointment at the insertion site.
- D. Ensure the catheter bag is always below bladder level.
Correct Answer: D
Rationale: The most crucial action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter is to ensure that the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Irrigating the catheter daily (Choice A) is unnecessary and can introduce pathogens. Changing the catheter every 72 hours (Choice B) is not recommended unless clinically indicated to prevent introducing new pathogens. Applying antibiotic ointment at the insertion site (Choice C) is not the most important action to prevent CAUTIs; proper hygiene and maintaining a closed system are more critical.
The nurse is caring for a client who is postoperative following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?
- A. Keep the client in a low Fowler's position.
- B. Maintain hip abduction with pillows.
- C. Encourage early ambulation.
- D. Place the client in a prone position.
Correct Answer: B
Rationale: Maintaining hip abduction with pillows is the most important intervention to prevent dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and prevents excessive internal rotation, which can lead to dislocation. Keeping the client in a low Fowler's position (Choice A) does not provide the necessary support and stability for the hip joint. While early ambulation (Choice C) is important for preventing complications such as blood clots and promoting circulation, it is not the most crucial intervention for preventing dislocation. Placing the client in a prone position (Choice D) can be harmful and increase the risk of dislocation.
A client with a diagnosis of chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). What is the primary goal of this medication?
- A. To reduce the risk of bleeding.
- B. To lower blood pressure.
- C. To stimulate red blood cell production.
- D. To increase appetite.
Correct Answer: C
Rationale: The correct answer is C: 'To stimulate red blood cell production.' Epoetin alfa, such as Epogen, is used to treat anemia by stimulating red blood cell production in clients with chronic kidney disease. This medication helps increase hemoglobin levels and reduce the need for blood transfusions. Option A, 'To reduce the risk of bleeding,' is incorrect as epoetin alfa does not directly impact bleeding risk. Option B, 'To lower blood pressure,' is incorrect as epoetin alfa is not indicated for blood pressure management. Option D, 'To increase appetite,' is also incorrect as the primary goal of epoetin alfa is related to improving anemia by boosting red blood cell production.
The nurse observes that a post-operative client's surgical wound has reddened edges and is oozing. What is the appropriate nursing action?
- A. Apply an antibiotic ointment
- B. Clean the wound with sterile saline
- C. Cover the wound with a sterile dressing
- D. Notify the surgeon immediately
Correct Answer: D
Rationale: The correct action when a post-operative client's surgical wound has reddened edges and is oozing is to notify the surgeon immediately. Reddened, oozing wound edges can indicate an infection that requires prompt evaluation and intervention by the surgical team. Applying an antibiotic ointment (Choice A) without proper assessment and guidance can be inappropriate. Cleaning the wound with sterile saline (Choice B) and covering it with a sterile dressing (Choice C) may not address the potential infection adequately, and the client may require more specialized care that the surgeon can provide.