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The patient admitted with diabetic ketoacidosis has rapid, deep respirations. What action should the nurse take?
- A. Administer the prescribed PRN lorazepam (Ativan).
- B. Start the prescribed PRN oxygen at 2 to 4 L/min.
- C. Administer the prescribed normal saline bolus and insulin.
- D. Encourage the patient to practice guided imagery for relaxation.
Correct Answer: C
Rationale: The correct answer is C, administer the prescribed normal saline bolus and insulin. In diabetic ketoacidosis, rapid, deep respirations, known as Kussmaul breathing, occur due to compensatory mechanisms to lower blood pH. Normal saline bolus helps correct dehydration and insulin therapy helps lower blood sugar levels, leading to improved acidosis. Option A is incorrect as lorazepam does not address the underlying cause of the rapid respirations. Option B is incorrect as oxygen is not the priority in this situation. Option D is incorrect as guided imagery does not address the physiological needs of the patient in this critical condition.
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A patient with anemia is prescribed ferrous sulfate. What advice should the nurse give regarding the administration of this medication?
- A. Take with dairy products to increase absorption.
- B. Take on an empty stomach for best absorption.
- C. Avoid vitamin C while taking this medication.
- D. Take before bedtime.
Correct Answer: B
Rationale: The correct answer is B: Take on an empty stomach for best absorption. Ferrous sulfate is best absorbed on an empty stomach to maximize its effectiveness. When taken with food or dairy products (Choice A), the absorption of iron is reduced. Vitamin C actually enhances the absorption of iron, so avoiding it (Choice C) is not recommended. Taking the medication before bedtime (Choice D) may lead to gastrointestinal side effects and is not optimal for absorption.
A patient with tuberculosis is started on rifampin. What advice should the nurse provide?
- A. Limit intake of green leafy vegetables.
- B. Expect orange-red discoloration of body fluids.
- C. Avoid exposure to sunlight.
- D. Take the medication with antacids.
Correct Answer: B
Rationale: The correct answer is B: Expect orange-red discoloration of body fluids. Rifampin is known to cause a harmless side effect of discoloration of body fluids, such as urine, sweat, saliva, and tears, turning them orange-red. This is a common occurrence and should be expected by the patient.
Incorrect choices:
A: Limit intake of green leafy vegetables - This advice is not necessary with rifampin.
C: Avoid exposure to sunlight - There is no direct association between rifampin and sunlight exposure.
D: Take the medication with antacids - Rifampin should not be taken with antacids as they can interfere with its absorption.
In summary, the correct answer is B because it aligns with a known side effect of rifampin, while the other choices are not relevant to the medication.
A client with a new diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). Which instruction should the nurse include in the client's teaching?
- A. Take the medication with food to prevent gastrointestinal upset.
- B. Take the medication 30 minutes before meals.
- C. Avoid dairy products while taking this medication.
- D. Take the medication at bedtime.
Correct Answer: B
Rationale: The correct answer is B: Take the medication 30 minutes before meals. Pyridostigmine is a cholinesterase inhibitor used to treat myasthenia gravis by improving muscle strength. Taking it before meals helps optimize its effects when muscle strength is needed the most during eating. Taking it with food (A) may delay absorption. Avoiding dairy products (C) is not necessary with pyridostigmine. Taking the medication at bedtime (D) may not be optimal for addressing muscle weakness during meal times.
A patient with Parkinson's disease is prescribed levodopa. What dietary modification should the nurse suggest to the patient?
- A. Increase intake of vitamin C.
- B. Limit foods high in protein.
- C. Avoid foods rich in fiber.
- D. Increase sodium intake.
Correct Answer: B
Rationale: The correct answer is B: Limit foods high in protein. Levodopa competes with amino acids for absorption in the small intestine, so consuming high-protein foods can reduce its effectiveness. Limiting protein intake can help maximize the absorption and efficacy of levodopa. Increasing vitamin C (option A) is not directly related to levodopa metabolism. Avoiding fiber (option C) is not necessary for levodopa therapy. Increasing sodium intake (option D) is not indicated for levodopa treatment in Parkinson's disease.
A patient with hyperthyroidism is to receive radioactive iodine therapy. What information should the nurse include in the patient teaching plan?
- A. Avoid close contact with pregnant women for one week.
- B. Take iodine supplement daily.
- C. Restrict fluid intake to 1 liter per day.
- D. Use disposable utensils for all meals.
Correct Answer: A
Rationale: The correct answer is A. The rationale is that radioactive iodine therapy can harm a developing fetus, so patients should avoid close contact with pregnant women for one week. Choice B is incorrect as iodine supplements can interfere with the therapy. Choice C is incorrect as fluid intake should not be restricted unless specifically advised by the healthcare provider. Choice D is incorrect as there is no need to use disposable utensils for all meals.