Nokea
The nurse is teaching a client with a new diagnosis of multiple sclerosis about interferon beta-1a (Avonex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any fever or flu-like symptoms
- C. Stop the medication if symptoms improve
- D. Avoid regular neurological exams
Correct Answer: B
Rationale: Fever or flu-like symptoms are common interferon beta-1a side effects but may also indicate infection, requiring reporting. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks relapse, and exams are essential.
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A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
An adult is hospitalized for heart failure. Hydrochlorothiazide and digoxin are prescribed. What laboratory test(s) should the nurse monitor because the client is taking these medications?
- A. CBC and differential
- B. Serum creatinine and BUN
- C. Cardiac enzymes
- D. Serum electrolytes
Correct Answer: D
Rationale: Hydrochlorothiazide and digoxin can cause electrolyte imbalances (e.g., hypokalemia), increasing digoxin toxicity risk, necessitating serum electrolyte monitoring.
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
- A. Change the baby to whole milk
- B. Add chocolate syrup to the bottle
- C. Continue with the present formula
- D. Offer fruit juice frequently
Correct Answer: C
Rationale: Continue with the present formula. Switching to whole milk before 12 months can lead to allergies and lactose intolerance.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I brush my teeth twice a day.
- B. I take my medication with milk.
- C. I have a rash on my arms.
- D. I feel drowsy in the morning.
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.