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Which instructions should the nurse include when reinforcing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply.
- A. Avoid foods that may cause epigastric distress such as spicy or acidic foods.
- B. It is best if you refrain from consuming alcohol products.
- C. Report black tarry stools to your health care provider immediately
- D. Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days.
- E. You may take over-the-counter drugs such as aspirin if you have mild epigastric pain.
Correct Answer: A,B,C,D
Rationale: Avoiding irritants (A), abstaining from alcohol (B), reporting melena (C), and completing the antibiotic regimen (D) are critical for managing H. pylori-related peptic ulcer disease.
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The nurse is auscultating a client's breath sounds and identifies rhonchi. The nurse should recognize that rhonchi is consistent with
- A. croup
- B. pleurisy
- C. bronchitis
- D. pneumothorax
Correct Answer: C
Rationale: Rhonchi are low-pitched, rattling sounds caused by mucus or fluid in larger airways, commonly associated with bronchitis.
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
- A. bounding pulse
- B. rapid respirations
- C. oliguria
- D. neck veins are distended
Correct Answer: C
Rationale: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.
A client who has Type 1 diabetes mellitus is admitted for alcohol detoxification. A moderate sliding scale for insulin is ordered. How often should the nurse expect to take glucose levels?
- A. Every time medication is administered
- B. When the client is symptomatic
- C. Before meals and at bedtime
- D. Every two hours
Correct Answer: C
Rationale: Sliding scale insulin for Type 1 diabetes requires glucose checks before meals and at bedtime to adjust dosing, ensuring glycemic control.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.