Nokea
The nurse is performing teaching for a client being discharged on clozapine (Clozaril).
Which of the following client statements indicates to the nurse that teaching has been successful?
- A. I need to call my doctor in a few weeks for a follow-up appointment.'
- B. I need to keep my doctor's appointment next week for a blood Test .'
- C. I can take over-the-counter sedatives if I have trouble sleeping.'
- D. I can drink alcohol as long as I drink in moderation.'
Correct Answer: B
Rationale: Strategy: 'Teaching has been successful' indicates a correct response. (1) follow routine schedule (2) correct-Clozaril causes agranulocytosis; requires weekly WBC; teach client to report early signs of infection (3) check with physician before taking any OTC medication (4) check with physician before ingesting alcohol
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A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.
After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority?
- A. Decrease IV fluids.
- B. Assess the fetal heart monitor.
- C. Place the mother on her right side.
- D. Obtain the blood pressure.
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring the priority to detect complications. Options A, B, and C are secondary or incorrect.
A newborn is to be discharged in the AM.
The nurse should teach the child's mother to perform which of the following actions?
- A. Apply a sterile gauze dressing with petroleum jelly to the cord.
- B. Position the diaper over the umbilicus to keep it dry.
- C. Clean the cord several times a day and expose it to air frequently.
- D. Apply erythromycin ointment to the cord several times a day.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) appropriate for circumcision (2) will keep the area moist; the diaper should be placed below the umbilicus (3) correct-encourages drying and helps to prevent infection (4) antibiotic ointment is unnecessary
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the 'unfreezing' phase of change. With this approach the nurse manager should:
- A. Discuss with the staff how to deal with any defensive behavior
- B. Explain to the unit staff why change is necessary
- C. Assist the staff during the acceptance of the new changes
- D. Clarify what the changes mean to the community and hospital
Correct Answer: B
Rationale: Explain to the unit staff why change is necessary. The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it.
Delirium tremens could best be described as
- A. Disorganized thinking, feelings of terror and non-purposeful behavior
- B. A generalized shaking of the body accompanied by repetitive thoughts
- C. An excited state accompanied by disorientation, hallucination and tachycardia
- D. Single or multiple jerks caused by rapid contracting muscles
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.