Nokea
A 76-year-old man receiving isoniazid (INH) 200 mg every day for 6 months.
The nurse would be MOST concerned if the client made which of the following statements?
- A. I have blurred vision at times.'
- B. My legs and knees hurt.'
- C. My hands and feet tingle.'
- D. I think I had a migraine yesterday.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to Isoniazid. (1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct-may cause peripheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication
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The client who is scheduled for a knee replacement asks the nurse why she should donate her own blood before surgery. How should the nurse respond?
- A. The blood bank is very short of blood.'
- B. Your own blood is the correct type for you.'
- C. It eliminates the chance of blood-borne diseases such as hepatitis and HIV.'
- D. Your own blood increases your energy level after surgery.'
Correct Answer: C
Rationale: Autologous blood donation eliminates transfusion-related infection risks, like hepatitis or HIV, ensuring safety during surgery.
The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has Vectors are not supported in text mode. Please provide the text content you want to include, and I'll help format it appropriately. to have the CBI. Which of the following responses by the nurse is BEST?
- A. The CBI prevents urinary stasis and infection.
- B. The CBI dilutes the urine to prevent infection.
- C. The CBI enables urine to keep flowing.
- D. The CBI delivers medication to the bladder.
Correct Answer: C
Rationale: continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
The nurse is caring for a client with a history of heart failure who is receiving torsemide (Demadex) 20 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L
- B. Sodium 140 mEq/L
- C. Creatinine 1.2 mg/dL
- D. Glucose 100 mg/dL
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) is a serious torsemide side effect, risking arrhythmias in heart failure. Options B, C, and D are normal.
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
- A. The client's arms and legs are exercised every day.
- B. The daughter gets her mother out of bed several times a day.
- C. The client is given a shower every other day.
- D. The daughter puts the chair on the right side of the bed when getting her mother out of bed.
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.
The nurse is teaching a client about the toxicity of digoxin. Which one of the following statements made by the client to the nurse indicates more teaching is needed?
- A. I may experience a loss of appetite.'
- B. I can expect occasional double vision.'
- C. Nausea and vomiting may last a few days.'
- D. I must report a bounding pulse of 62 immediately.'
Correct Answer: D
Rationale: Slow heart rate is related to increased cardiac output and an intended effect of digoxin. The ideal heart rate is above 60 BPM with digoxin. The client needs further teaching.