Nokea
The nurse is working on a discharge teaching plan for a client prescribed phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI drug). The nurse knows teaching was successful if the client states,
- A. I will not be able to have wine and aged cheese anymore.'
- B. I should avoid all dairy products from now on.'
- C. Taking this medication with vitamin K-containing foods is dangerous.'
- D. I will need to decrease my dietary fiber now.'
Correct Answer: A
Rationale: MAOIs like phenelzine require avoiding tyramine-rich foods (e.g., wine, aged cheese) to prevent hypertensive crisis. Dairy, vitamin K, and fiber are not contraindicated.
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The nurse is providing discharge teaching to a client newly diagnosed with heart failure. Which statement by the client indicates an understanding of the side effects of furosemide (Lasix)?
- A. I should eat bananas, dried dates, or peaches every day.
- B. I should check my heart rate before taking this medicine.
- C. I will avoid foods containing tyramine while on this medicine.
- D. I will not take the medicine when I have to go on a long car trip.
Correct Answer: A
Rationale: Furosemide can cause potassium loss; eating potassium-rich foods like bananas, dates, or peaches shows understanding of managing this side effect.
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
- A. Perform passive range-of-motion exercises before walking.
- B. Encourage partial weight bearing while ambulating.
- C. Immobilize the extremity between activities.
- D. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: would relieve weight, pressure, and stress on affected leg, may use walker
A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?
- A. Prepare the client for a caesarean section
- B. Apply the fetal heart monitor
- C. Place the client in the Trendelenburg position
- D. Perform an ultrasound exam
Correct Answer: B
Rationale: Applying the fetal heart monitor assesses fetal well-being in a breech presentation, guiding further management.
The nurse is caring for a client with leukemia who has received the drug (daunorubicin) Cerubidine. Which of the following common side effects would cause the most concern?
- A. Nausea
- B. Vomiting
- C. Cardiotoxicity
- D. Alopecia
Correct Answer: C
Rationale: Daunorubicin is known for cardiotoxicity, which can lead to heart failure and is life-threatening, making it the most concerning side effect. Nausea, vomiting, and alopecia are common but less severe.
A client has orders for a heparin drip with 20,000 units in a 250 mL bag. The heparin must be delivered at 854 units per hour. What rate will the nurse set for the IV?
Correct Answer: 10.7 mL/hr.
Rationale: Concentration: 20,000 units/250 mL = 80 units/mL. Rate: 854 units/hr ÷ 80 units/mL = 10.675 mL/hr, rounded to 10.7 mL/hr.