Nokea
The nurse is teaching a client with a new diagnosis of gout about dietary management. Which of the following foods should the client include?
- A. Cherries.
- B. Red meat.
- C. Shellfish.
- D. Organ meats.
Correct Answer: A
Rationale: Cherries reduce uric acid levels and inflammation in gout.
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The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.
- A. Check that the dose is appropriate for the child's weight.
- B. Note that the onset of the medication will be immediate.
- C. Follow the administration of the bolus of heparin with an I.V. infusion of heparin 10 units/kg/hour.
- D. Monitor partial thromboplastin time (PTT).
- E. Discontinue the penicillin until the PTT is at a therapeutic level.
Correct Answer: A,C,D
Rationale: Verifying the dose, administering a maintenance infusion, and monitoring PTT are standard for heparin therapy. Heparin's onset is immediate for I.V. but not a primary concern. Penicillin does not need discontinuation.
A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client?
- A. Control hemorrhaging.
- B. Replace fluids.
- C. Relieve the client's anxiety.
- D. Maintain a patent airway.
Correct Answer: D, A, B, C
Rationale: The priority is to maintain a patent airway, control hemorrhaging, replace fluids, and then address anxiety to stabilize the client.
You are caring for a hospice client who is at the end of life. Based on this client's signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client?
- A. The client will be free of constipation
- B. The client will remain free of pain and distress
- C. The administration of an antiemetic to prevent vomiting and further dehydration
- D. The administration of an enema to correct the constipation
Correct Answer: B
Rationale: Given the client's comatose state and imminent death, the priority is to maintain comfort. Ensuring the client remains free of pain and distress is the most appropriate outcome, as aggressive interventions like enemas or antiemetics are less relevant in this context.
A client with a history of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hyperglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Clozapine can cause agranulocytosis, requiring regular white blood cell monitoring.
Pelvic inflammatory disease is most often caused by:
- A. Trichomoniasis
- B. E. coli
- C. Staphylococcus aureus
- D. Neisseria gonorrhoeae
Correct Answer: D
Rationale: Neisseria gonorrhoeae is a common cause of pelvic inflammatory disease, often resulting from untreated gonorrhea, leading to infection of the reproductive organs.