Nokea
The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct Answer: C
Rationale: Vinaigrette may contain alcohol, which reacts with disulfiram, causing severe symptoms.
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The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
- A. Assisting the LPN with opening sterile packages and peroxide
- B. Telling the LPN that clean gloves are allowed
- C. Telling the LPN that the registered nurse should perform pin care
- D. Asking the LPN to clean the weights and pulleys with peroxide
Correct Answer: A
Rationale: Sterile technique is appropriate for pin care; assisting maintains the sterile field.
A client with AIDS is admitted with a diagnosis of pneumocystis carinii pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based upon his mental status, the priority nursing diagnosis is:
- A. Social isolation
- B. Risk for injury
- C. Ineffective coping
- D. Anxiety
Correct Answer: B
Rationale: The client's confusion and disorientation pose a risk for injury, such as pulling out the IV or falling, making this the priority nursing diagnosis.
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
- A. Keep the bed flat, with a small pillow beneath the cast.
- B. Provide crayons and a coloring book for play activity.
- C. Increase her intake of high-calorie foods for healing.
- D. Tuck a disposable diaper beneath the cast at the perineal opening.
Correct Answer: D
Rationale: Tucking a diaper beneath the cast at the perineal opening helps keep the cast clean and prevents skin irritation.
Which selection would provide the most calcium for the client who is 4 months pregnant?
- A. A granola bar
- B. A bran muffin
- C. A cup of yogurt
- D. A glass of fruit juice
Correct Answer: C
Rationale: Yogurt is a rich source of calcium, essential for fetal bone development during pregnancy.
Skeletal traction is applied to the right femur of a client injured in a fall. The primary purpose of the skeletal traction is to:
- A. Realign the tibia and fibula
- B. Provide traction on the muscles
- C. Provide traction on the ligaments
- D. Realign femoral bone fragments
Correct Answer: D
Rationale: Skeletal traction for a femoral injury aims to realign femoral bone fragments, promoting proper healing and preventing deformity.