Nokea
The nurse is teaching a client with a new diagnosis of epilepsy about self-care. Which of the following instructions should be included?
- A. Avoid swimming alone.
- B. Take medications at bedtime only.
- C. Limit fluid intake to prevent seizures.
- D. Wear loose-fitting clothing.
Correct Answer: A
Rationale: Avoiding swimming alone prevents drowning during a seizure, a key safety measure.
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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.
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.
A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
- A. Check the sodium level.
- B. Call the primary health care provider.
- C. Encourage an extra 500 mL of fluid intake.
- D. Teach the client about foods low in potassium.
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
A client with a history of type 2 diabetes mellitus is prescribed glipizide (Glucotrol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Hypoglycemia.
- C. Weight gain.
- D. Fatigue.
Correct Answer: B
Rationale: Hypoglycemia is a serious side effect of glipizide, requiring immediate reporting to prevent complications.
The mother of a child with moderate diarrhea asks how to manage her child's illness. Which of the following should the nurse suggest?
- A. Begin clear liquids for 24 hours.
- B. Feed the child bananas, rice, applesauce, and toast.
- C. Offer foods that are low in fat.
- D. Continue the child's regular diet.
Correct Answer: B
Rationale: The BRAT diet (bananas, rice, applesauce, toast) is recommended for moderate diarrhea in children to provide easily digestible, low-fiber foods that help firm stools.