Nokea
A client receiving tetracycline.
The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
- A. Take the medication with milk or antacids to decrease GI problems.
- B. The medication should always be taken with meals.
- C. Use a maximum-protection sunscreen when outdoors.
- D. Crackers and juice will help decrease gastric irritation.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tetracycline should never be taken with milk or antacids as these inhibit the medication's action (2) should take with full glass of water at least one hour before or two hours after meals (3) correct-because of problems related to photosensitivity, sunscreen, wide-brimmed hats, and long sleeves should be worn when client is at risk for sun exposure (4) should take with full glass of water at least one hour before or two hours after meals
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Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.
An adult has received an injection of immunoglobulin. The client asks what this injection will do for him. The nurse's reply includes the information that he will develop which type of immunity as a result of this injection?
- A. Active natural immunity
- B. Active artificial immunity
- C. Passive natural immunity
- D. Passive artificial immunity
Correct Answer: D
Rationale: Immunoglobulin provides preformed antibodies, conferring passive artificial immunity. Active immunity requires the body to produce antibodies, and natural immunity involves natural exposure.
The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
- A. The client should stay isolated from the rest of the family.
- B. No one who is pregnant should care for the client.
- C. The family should wash hands before and after caring for the client.
- D. The client should not be allowed to have any visitors.
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.
A 56-year-old woman is receiving digoxin (Lanoxin) 0.25 mg PO qd and furosemide (Lasix) 40 mg PO bid. She calls her physician for complaints of mild diarrhea. The physician prescribes Kaopectate 60 mg after each bowel movement for 2 days and instructs her to call back if symptoms don't subside.
The nurse should instruct the woman to
- A. make no changes in her medication schedule.
- B. wait 1 hour before taking her scheduled medications if she takes the Kaopectate.
- C. hold her scheduled medications until the diarrhea subsides.
- D. take the Lanoxin but hold the Lasix if she takes the Kaopectate.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) PO meds would be absorbed by Kaopectate not by stomach (2) correct-Kaopectate absorbs PO meds, separate administration of other meds (3) other meds should be given later (4) both meds should be given later
Under the supervision of the registered nurse, a student nurse is changing the dressing of a 49-year-old woman with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, would require an intervention by the registered nurse?
- A. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine.
- B. The student nurse applies two sterile precut 4 × 4s to the catheter insertion site.
- C. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site.
- D. The student nurse securely tapes the edges of the sterile dressing with paper tape.
Correct Answer: C
Rationale: should clean from insertion site outward toward outer abdomen