Nokea
The nurse should teach a client in the Emergency Department, who has suffered an ankle sprain, to:
- A. Use cold applications to the sprain during the first 24-48 hours
- B. Expect disability to decrease within the first 24 hours of injury
- C. Expect pain to decrease within 3 hours after injury
- D. Begin progressive passive and active range of motion exercises immediately
Correct Answer: A
Rationale: Cold applications reduce edema and vasoconstriction in the first 24-48 hours of an ankle sprain. Pain and disability may increase initially, and exercises begin later per physician guidance.
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The nurse teaches the client who has lesions that have not healed and are recurring about the newly prescribed medication ganciclovir. The nurse should document that teaching about ganciclovir was completed for the client with which illustrated condition?
- A. ganeiclovir_1.PNG
- B. ganeiclovir_2.PNG
- C. ganeiclovir_3.PNG
- D. ganeiclovir_4.PNG
Correct Answer: D
Rationale: A: Client A has vitiligo, a skin disorder characterized by the patchy loss of skin pigment. Vitiligo is treated with topical steroids. B: Client B has dried herpes simplex, usually treated with the antiviral medication acyclovir. C: Client C has keloids (hypertrophic scarring), which usually are not treated with medication. D: Ganciclovir (Cytovene) is an antiviral medication used in the treatment of recurrent genital herpes.
The 30-year-old has been taking olanzapine for the past 5 years for the treatment of schizophrenia. The client, who has a positive family history of DM, is now overweight but is not showing signs of hyperglycemia. When the client asks about the next steps for treatment, how should the nurse respond?
- A. You'll be started on an oral hyperglycemic agent.
- B. I will be teaching you how to self-administer insulin.
- C. You'll need to have a fasting blood glucose level drawn.
- D. Olanzapine will be discontinued and another drug started.
Correct Answer: C
Rationale: Due to the risk of hyperglycemia with olanzapine (Zyprexa), blood glucose testing is needed to determine if medication therapy is indicated.
The 5-year-old is receiving an IV infusion of D5 with 0.45 NaCl at 100 mL/hr. Which assessment findings suggest excessive parenteral fluid intake? Select all that apply.
- A. Dyspnea
- B. Lethargy
- C. Gastric distention
- D. Crackles in lung bases
- E. Temperature of 102°F (38.9°C)
Correct Answer: A,B,D
Rationale: A: Dyspnea indicates fluid volume overload and occurs from fluid rapidly shifting between the intracellular and extracellular compartments. B: Lethargy and change in level of consciousness can occur from fluid shifting in brain cells. C: Gastric distention can occur from excessive oral (not IV) fluid intake or infection. D: Crackles indicate fluid volume overload and occur from fluid rapidly shifting into the alveoli. E: An elevated temperature is a sign of fluid volume deficit, not excess.
The client who is to receive a scheduled dose of digoxin has an irregular apical pulse at 92 bpm and a serum potassium of 3.9 mEq/L. Which nursing documentation reflects the most appropriate action?
- A. Serum potassium level WNL. Digoxin given for rapid apical pulse.
- B. Digoxin withheld because the client's apical heart rate is irregular.
- C. Digoxin withheld to prevent toxicity due to the low potassium level.
- D. HCP informed of irregular heart rate and low serum potassium level.
Correct Answer: A
Rationale: A: A normal serum potassium level is 3.5 to 5.0 mEq/L. Digoxin (Lanoxin), a cardiac glycoside, slows and strengthens the heart. It is used for rate control in clients with atrial fibrillation, which often produces an irregular rhythm. B: Dysrhythmias can occur if digoxin is given when the serum potassium level is low, but the serum potassium level is WNL. Digoxin is used for rate control and would not be withheld due to an irregular HR. C: Although it is important to monitor for digoxin toxicity, the serum potassium level is WNL. D: Withholding digoxin and notifying the HCP are unnecessary; the serum potassium is WNL.
A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct Answer: B
Rationale: A client taking an MAO Inhibitor, such as phenelzine (Nardil), should avoid tyramine-rich foods, which includes avocados, bananas, and salami.