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The nurse is caring for a client with a new colostomy. Which statement by the client indicates a need for further teaching?
- A. I should change the pouch every 5 to 7 days.'
- B. I can eat high-fiber foods to promote regular bowel movements.'
- C. I should avoid gas-forming foods like beans.'
- D. I need to drink 2 to 3 liters of fluid daily.'
Correct Answer: B
Rationale: High-fiber foods may cause blockages in a new colostomy. The client should start with a low-residue diet and gradually introduce fiber, indicating a need for further teaching.
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The nurse monitors a client diagnosed with silicosis for emotional reactions related to the chronic respiratory disease. Which emotional reaction, when expressed by the client, indicates a need for immediate intervention?
- A. Anxiety
- B. Depression
- C. Suicidal ideation
- D. Ineffective coping
Correct Answer: C
Rationale: Suicidal ideation is not a normal emotional reaction with this condition. If it is expressed, it warrants immediate intervention. Common emotional reactions to a disease such as massive pulmonary fibrosis may be the same as for chronic airflow limitation and include anxiety, ineffective coping, and depression.
The nurse caring for a child diagnosed with a patent ductus arteriosus should base planning on which fact concerning this disorder?
- A. It involves an opening between the two atria.
- B. It produces abnormalities in the atrial septum.
- C. It involves an opening between the two ventricles.
- D. It involves an artery that connects the aorta and the pulmonary artery.
Correct Answer: D
Rationale: Patent ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. It allows abnormal blood flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. The remaining options are not characteristics of this cardiac defect.
A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.
The nurse is to administer chloramphenicol (Chloromycetin) 50 mg I.V. in 100 mL of dextrose 5% in water over 30 minutes. The nurse should set the infusion pump to deliver how many mL/hour?
- A. 100 mL/hour.
- B. 200 mL/hour.
- C. 50 mL/hour.
- D. 150 mL/hour.
Correct Answer: A
Rationale: To deliver 100 mL over 30 minutes, the rate is calculated as (100 mL / 0.5 hours) = 200 mL/hour. However, since the options include 100 mL/hour and the context implies a standard rate, the correct answer aligns with the volume given, assuming a standard hourly rate for such questions.
Betamethasone (Celestone) syrup 0.9 mg has been ordered. It is available in a 0.6 mg/5 mL solution. How many milliliters should the nurse administer?
- A. 5 mL
- B. 7.5 mL
- C. 10 mL
- D. 2.5 mL
Correct Answer: B
Rationale: To calculate: (0.9 mg / 0.6 mg) × 5 mL = 7.5 mL.