Nokea
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection.
The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment is to
- A. minimize the bacterial count in the mouth.
- B. soften the mucous membranes of the tongue before surgery.
- C. stimulate the microcirculation of the mouth.
- D. hydrate the tissues of the gums.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the procedure. (1) correct-destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes
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An adult has completed an alcohol detoxification program and is being discharged with disulfiram (Antabuse). Which statement that the client makes indicates a need for more teaching?
- A. I have learned my lesson. I won't drink more than two beers.'
- B. I will not use mouthwash while I am taking Antabuse.'
- C. I should take the Antabuse every day.'
- D. If I have to go to the emergency room for any reason, I will tell them I take Antabuse.'
Correct Answer: A
Rationale: Planning to drink alcohol (even minimally) while on disulfiram indicates misunderstanding, as it causes severe reactions with alcohol. Other statements show proper understanding.
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
The nurse returns to the nurse's station after making client rounds and finds four phone messages.
Which of the following messages should the nurse return FIRST?
- A. A client with hepatitis A who states, 'My arms and legs are itching.'
- B. A client with a cast on the right leg who states, 'I have a funny feeling in my right leg.'
- C. A client with osteomyelitis of the spine who states, 'I am so nauseous that I can't eat.'
- D. A client with arthritis who states, 'I am having trouble sleeping at night.'
Correct Answer: B
Rationale: Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat with calamine lotion and antihistamines (2) correct-may indicate neurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following instructions should the nurse include?
- A. Take the medication daily to prevent migraines.
- B. Report any chest pain.
- C. Stop the medication if headaches decrease.
- D. Avoid regular neurological exams.
Correct Answer: B
Rationale: Chest pain may indicate vasoconstriction, a serious sumatriptan side effect. Options A, C, and D are incorrect.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.