Nokea
The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take?
- A. Obtain the client's blood pressure.
- B. Check the client's pancreatic enzyme levels.
- C. Verify placement of the tube after administering the medication.
- D. Holdphysics://www.youtube.com/watch?v=9Q7sE1Xh_1QHold the enteral feeding for 1 hour before administering the medication.
Correct Answer: D
Rationale: Phenytoin binds to enteral feedings, reducing absorption. Holding feedings for 1 hour before and after administration ensures efficacy. Tube placement should be verified before, not after, administration. Blood pressure and pancreatic enzymes are unrelated.
You may also like to solve these questions
Written instructions to pregnant women include instructions to perform Kegel exercises. One of the women asks the nurse why these exercises are important. The nurse should reply that the purpose of these exercises is to:
- A. increase circulation to the uterus.
- B. strengthen the muscles of the pelvic floor.
- C. prepare the breasts for nursing.
- D. condition the pregnant woman for the 'work' of childbirth.
Correct Answer: B
Rationale: Kegel exercises strengthen pelvic floor muscles, supporting bladder control and aiding postpartum recovery, directly addressing their purpose.
The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?
- A. Hoarseness
- B. Signs of hypercalcemia
- C. Loss of reflexes
- D. Mental confusion
Correct Answer: B
Rationale: Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.
A client with tuberculosis has an order for Rifadin (rifampin). What vitamin is usually given with rifampin?
- A. Thiamine
- B. Pyridoxine
- C. Folic acid
- D. Cyanocobalamin
Correct Answer: B
Rationale: Pyridoxine (vitamin B6) is given with rifampin to prevent peripheral neuropathy, a side effect. Other vitamins are not typically associated with rifampin therapy.
The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?
- A. Nausea and vomiting
- B. Anxiety
- C. Hallucinations
- D. Seizures
Correct Answer: D
Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.
The nurse is caring for a client with type 1 diabetes mellitus who is reporting abdominal pain and weakness. The client has a fruity odor to the breath and rapid, deep respirations. Which of the following actions should the nurse take? Select all that apply.
- A. Instruct the client to breathe into a paper bag
- B. Check the client's capillary blood glucose level.
- C. Place the client on a continuous cardiac monitor.
- D. Prepare the client for an IV infusion of regular insulin.
- E. Gather supplies for an IV bolus of 0.9% sodium chloride
Correct Answer: B,C,D,E
Rationale: Symptoms suggest diabetic ketoacidosis (DKA). Checking glucose confirms hyperglycemia, cardiac monitoring detects arrhythmias from electrolyte imbalances, IV insulin corrects hyperglycemia, and saline bolus addresses dehydration. Breathing into a paper bag is for hyperventilation from anxiety, not DKA.