Nokea
Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply.
- A. Warm the fingers or toes by using an electric heating pad
- B. Wear warm socks or gloves when exposed to cold temperatures
- C. Check the temperature of bath water before entering
- D. Use a hot water bottle to warm feet at night
- E. Avoid crossing the legs when sitting
- F. Use a heating blanket when cold
Correct Answer: B,C,E,G
Rationale: Clients with peripheral vascular disease should wear warm clothing, check bath water temperature, avoid crossing legs to maintain circulation, and use sunscreen to protect skin. Electric heating pads, hot water bottles, and heating blankets risk burns due to impaired sensation.
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A client with a history of chronic kidney disease is prescribed calcitriol (Rocaltrol). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Increasing calcium absorption.
- C. Decreasing phosphate levels.
- D. Increasing urine output.
Correct Answer: B
Rationale: Calcitriol, a vitamin D analog, increases calcium absorption in chronic kidney disease to correct hypocalcemia.
When a daily dose of fluoxetine hydrochloride is prescribed for a client, the nurse provides instructions regarding its administration. Which statement by the client indicates an understanding regarding the administration of the medication?
- A. I should take the medication with food only.
- B. It is best to take the medication in the morning.
- C. I should take the medication at bedtime with a snack.
- D. I should take the medication at noontime with an antacid.
Correct Answer: B
Rationale: A daily dose of fluoxetine hydrochloride, a selective serotonin reuptake inhibitor (SSRI), should be taken in the morning. If the medication is prescribed more than once daily, then the client is instructed to take the last dose of the day before 4:00 pm to avoid insomnia. It does not have to be taken with food. Antacids are avoided with its administration because the antacid will affect absorption.
The nurse is caring for a client with a history of hyperthyroidism who is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hypertension.
- C. Hyperglycemia.
- D. Weight loss.
Correct Answer: A
Rationale: Methimazole can cause agranulocytosis, a serious reduction in white blood cells, requiring monitoring.
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
- A. Performing oral care every 4 hours.
- B. Elevating the head of the bed to 30-45 degrees.
- C. Administering prophylactic antibiotics.
- D. Suctioning the endotracheal tube every 2 hours.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.
A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
- A. 1 cup of lentils
- B. 1 cup of sunflower seeds
- C. 1/2oz of hard cheese
- D. 2 poached eggs
Correct Answer: A
Rationale: Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.