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The nurse is caring for a client with a history of anaphylaxis to peanuts. Which precaution is most important?
- A. Keep an epinephrine auto-injector at the bedside.
- B. Place the client in a private room.
- C. Administer antihistamines daily.
- D. Monitor for respiratory distress every 4 hours.
Correct Answer: A
Rationale: An epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Private rooms, antihistamines, and monitoring are secondary to ensuring rapid emergency response.
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The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?
- A. Mashed potatoes
- B. Smooth peanut butter
- C. Fried fish
- D. Rice
Correct Answer: C
Rationale: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.
A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:
- A. Monitoring heart rate
- B. Administering pain medication
- C. Monitoring respiratory rate
- D. Administering diuretics
Correct Answer: A
Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.
Which one of the following statements is correct when measuring the client for crutches?
- A. A distance of five fingerbreadths should exist between the top of the crutch and the axilla.
- B. The nurse should measure three inches between the top of the crutch and the axilla.
- C. The client's elbows should be flexed at a 10° angle.
- D. The crutches should be extended 8 to 10 inches from the side of the foot.
Correct Answer: B
Rationale: Proper crutch fitting requires a gap of about three inches (or two to three fingerbreadths) between the crutch top and the axilla to prevent nerve damage. The elbow should flex at about 30°, and crutches extend about 6 inches laterally from the foot.
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
- A. Administering diazepam (Valium) 10-15 mg po q4h and q1h prn for hyperventilating episode
- B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation
- C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
- D. Using distraction to help control the client's hyperventilation episodes
Correct Answer: C
Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.
Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:
- A. Maintaining a high-humidified environment
- B. Furry, soft stuffed animals for play
- C. Showering 3-4 times a day
- D. Wrapping hands in soft cotton gloves
Correct Answer: D
Rationale: Maintaining a low-humidified environment. Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. Wrapping hands in soft cotton gloves to prevent skin damage during scratching.