Nokea
The nurse is caring for a client with clinical depression who is receiving a monoamine oxidase inhibitor (MAOI). When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?
- A. Avoid chocolate and cheese
- B. Take frequent naps
- C. Take the medication with milk
- D. Avoid walking without assistance
Correct Answer: A
Rationale: Avoid chocolate and cheese. Foods high in tryptophan, tyramine, and caffeine, such as chocolate, wine, and cheese may precipitate hypertensive crisis.
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The nurse assesses the hospitalized client and surveys the client's room. The client is Muslim. Which findings require the nurse's immediate attention to remove possible sources of infection? Select all that apply.
- A. A capped bottle of saline solution with a label stating that it was opened 10 hours ago.
- B. The abdominal dressing is saturated and seeping through to the client's gown and bed.
- C. An infusing intravenous (IV) tubing has no notation of the date when it was last changed.
- D. A container located in the bathroom that is labeled urine and has the client's initials.
- E. Opened packages of gauze sponges and abdominal pads sitting on the window sill.
- F. An uncovered cup of figs on the bedside table brought by a family member last evening.
Correct Answer: B,C,E,F
Rationale: B: A saturated dressing can harbor microorganisms, increasing infection risk. C: Unknown IV tubing change dates pose a risk as tubing should be changed every 72-96 hours. E: Opened dressing packages are contaminated and unsuitable for use. F: Uncovered food can attract microorganisms, requiring immediate attention.
The client with an infected leg wound receives treatment and a prescription for antibiotics during a clinic visit. Which information should the nurse emphasize when completing discharge teaching?
- A. Return to the clinic in one week for a repeat tetanus injection.
- B. Avoid disturbing the dressing until next week's visit with the provider.
- C. If you have chills and your temperature is over 101°F (38.3°C), call the HCP.
- D. Do not take cold medicines for 24 hours after starting the antibiotic.
Correct Answer: C
Rationale: C: Chills and fever over 101°F indicate possible antibiotic failure, requiring prompt reporting. A: Tetanus shots are not repeated weekly. B: Dressings need frequent changes for infected wounds. D: Cold medicines are generally safe unless contraindicated.
A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While repositioning the client, the nurse notices dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Prepare for blood transfusion
- D. Continue to monitor the rate of drainage
Correct Answer: D
Rationale: It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: Lower the oxygen rate. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis. Unless corrected, it can lead to the client's death.
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent episodes of alertness
Correct Answer: D
Rationale: A preschooler with intermittent episodes of alertness. A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump.