Nokea
The nurse is reviewing acetaminophen (APAP) toxicity with students. The nurse should remind students that the maximum acetaminophen dosage for an adult is
- A. 2,000 mg per day
- B. 4,000 mg per day
- C. 5,000 mg per day
- D. 6,000 mg per day
Correct Answer: B
Rationale: The maximum recommended adult dose of acetaminophen is 4,000 mg per day to avoid liver toxicity.
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A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
- A. Use of loperamide (Imodium).
- B. Fluid restriction.
- C. Low fiber, bland diet.
- D. Bowel regimen.
Correct Answer: D
Rationale: Vincristine commonly causes constipation due to neurotoxicity. A bowel regimen (e.g., stool softeners, laxatives) is essential to prevent and manage this side effect.
A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to:
- A. Adhere to a low-cholesterol diet.
- B. Supplement the diet with pyridoxine (vitamin B6).
- C. Get extra rest.
- D. Avoid excessive sun exposure.
Correct Answer: B
Rationale: Isoniazid can deplete vitamin B6, causing peripheral neuropathy; supplementation with pyridoxine prevents this. Diet, rest, and sun exposure are unrelated to this adverse effect.
If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:
- A. Try using an ambu bag.
- B. Decrease the rate of compressions.
- C. Intubate the client.
- D. Reposition the airway.
Correct Answer: D
Rationale: Failure of the chest to rise during rescue breaths suggests airway obstruction or improper positioning. Repositioning the airway (e.g., head-tilt-chin-lift) is the first step.
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustrationshown, which should the nurse do?
- A. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity.
- B. Notify the physician of the amount of chest tube drainage.
- C. Add water to maintain the water seal.
- D. Lower the drainage system to maintain gravity flow.
Correct Answer: D
Rationale: To promote chest tube drainage the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours.
A client with terminal cancer wishes to die at home. The nurse should:
- A. Arrange for home hospice services.
- B. Encourage hospitalization for better care.
- C. Advise against it due to lack of equipment.
- D. Inform the client it's not possible.
Correct Answer: A
Rationale: Arranging home hospice services supports the client's wish to die at home, providing necessary care and support in a comfortable environment.