Nokea
The physician prescribes sulfisoxazole (Gantrisin) 2 g PO qid for a client. Which of the following instructions is MOST important for the nurse to include when teaching the client about this medication?
- A. Drink plenty of fluids.
- B. Wear sunscreen when outdoors.
- C. Eliminate dairy products from your diet.
- D. Take this medication with meals.
Correct Answer: A
Rationale: Sulfisoxazole can cause crystalluria; adequate fluid intake prevents kidney stones. Options B, C, and D are less critical or incorrect.
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During a child's 18-month checkup, the mother remarks that her child is not doing any of the following. Which would cause most concern to the nurse?
- A. Speaking in full sentences
- B. Making eye contact
- C. Riding a tricycle
- D. Putting together a 24-piece jigsaw puzzle
Correct Answer: B
Rationale: Lack of eye contact at 18 months may indicate developmental issues like autism, warranting urgent evaluation, unlike the other age-appropriate delays.
A newly admitted client is exhibiting signs of severe anxiety. She is pacing back and forth and has difficulty concentrating on the nurse's questions. What nursing action is most appropriate at this time?
- A. Tell the client to sit down and get control of herself
- B. Leave the room until she regains control
- C. Whisper to her that everything will be all right
- D. Attend to her behavior and direct her to a quiet area
Correct Answer: D
Rationale: Directing the client to a quiet area reduces stimuli, helping manage severe anxiety. Commands, leaving, or whispering are ineffective or dismissive.
The nurse is caring for a client with a history of hyponatremia.
- A. Which intervention is most appropriate for a client with hyponatremia?
- B. Administer hypertonic saline slowly.
- C. Encourage a low-sodium diet.
- D. Restrict fluid intake.
- E. Administer a diuretic.
Correct Answer: A
Rationale: Administering hypertonic saline slowly corrects hyponatremia by raising serum sodium levels, preventing cerebral edema. Low-sodium diets worsen hyponatremia, fluid restriction is for hypervolemic cases, and diuretics are contraindicated.
A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client?
- A. Isograft
- B. Autograft
- C. Homograft
- D. Xenograft
Correct Answer: D
Rationale: A Jewish client may find a xenograft unacceptable due to religious dietary laws that prohibit the use of certain animal products, such as porcine grafts. An isograft (from an identical twin), autograft (from the client's own body), and homograft (from a human donor) are generally more acceptable. Answers A, B, and C are incorrect because they do not typically conflict with Jewish religious beliefs.
A 62-year-old man who is scheduled for a total laryngectomy.
Which of the following statements, if made by the family, would indicate to the nurse a need for further teaching?
- A. We will need to learn other ways to communicate with each other.'
- B. My father will require a special kind of tube in his neck for his airway.'
- C. My husband will require a feeding tube for several months.'
- D. My dad may develop some difficulty with taste and smell after the surgery.'
Correct Answer: C
Rationale: Strategy: 'Further teaching is necessary' indicates an incorrect response. (1) will communicate in writing initially, then artificial larynx or esophageal speech (2) will require laryngectomy tube to prevent scar tissue contracture (3) correct-requires nutritional support for 10 days until wound heals, then gradually resumes oral intake (4) common with total laryngectomy