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The physician has prescribed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:
- A. Hypertension
- B. Hyperthermia
- C. Hypotension
- D. Urinary retention
Correct Answer: A
Rationale: Tyramine with MAOIs like tranylcypromine can cause a hypertensive crisis.
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A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
- A. Have a Protime done monthly
- B. Eat more fruits and vegetables
- C. Drink more liquids
- D. Avoid crowds
Correct Answer: A
Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.
To minimize confusion in the elderly hospitalized client, the nurse should:
- A. Provide sensory stimulation by varying the daily routine
- B. Keep the room brightly lit and the television on to provide orientation to time
- C. Encourage visitors to limit visitation to phone calls to avoid overstimulation
- D. Provide explanations in a calm, caring manner to minimize anxiety
Correct Answer: D
Rationale: Calm, clear explanations reduce anxiety and confusion in elderly clients, promoting orientation and comfort in the hospital setting.
The nurse is teaching a client on the proper technique to use an inhaler with a spacer for asthma management. Which action by the client would require intervention by the nurse?
- A. The client shakes the unit vigorously 3 or 4 times.
- B. The client places the inhaler over his tongue and seals his lips tightly around it.
- C. The client administers the next puff immediately after exhaling.
- D. The client keeps his lips closed and holds his breath for at least 10 seconds before exhaling.
Correct Answer: B
Rationale: Placing the inhaler over the tongue obstructs the airway; lips should seal around the mouthpiece with the tongue underneath. Other actions are correct.
After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
- A. Mydriatics to facilitate removal
- B. Miotic medications such as Timoptic
- C. A laser to smooth and reshape the lens
- D. Silicone oil injections into the eyeball
Correct Answer: A
Rationale: Mydriatics are used to dilate the pupil, facilitating lens removal during cataract surgery.