Nokea
Which of the following is a priority for the nurse to include in the teaching of a client who was recently prescribed alprazolam (Xanax) as an oral medication?
- A. Monitor heart rate before taking the medication
- B. Monitor temperature daily
- C. Avoid unprotected exposure to sunlight
- D. Avoid alcohol
Correct Answer: D
Rationale: The correct answer is D: 'Avoid alcohol.' Alprazolam (Xanax) can have central nervous system depressant effects, which are exacerbated by alcohol. It is crucial to avoid alcohol while taking this medication to prevent severe sedation and respiratory depression. Monitoring heart rate (choice A) is not directly related to alprazolam administration. Monitoring temperature daily (choice B) is not a priority teaching point for a client prescribed alprazolam. Avoiding unprotected exposure to sunlight (choice C) is not specifically linked to the use of alprazolam.
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Which task could the PN safely delegate to the UAP?
- A. Oral feeding of a two-year-old child after application of a hip spica cast
- B. Assessment of the placement and patency of a NG tube
- C. Participation in staff rounds to record notes regarding client goals
- D. Evaluation of a client's incisional pain following narcotic administration
Correct Answer: A
Rationale: The correct answer is A because oral feeding of a child is a task that can be safely delegated to an unlicensed assistive personnel (UAP). This task involves providing basic care and does not require specialized nursing skills. Choices B, C, and D involve assessments, recording client goals, and evaluating pain, respectively, which all require specialized nursing knowledge, judgment, and skills. These tasks are not within the scope of practice for a UAP.
The client diagnosed with HIV is taught by the nurse that the condition is transmitted through
- A. the infection passed from a mother to her baby
- B. Tears
- C. human bites
- D. insect bites
Correct Answer: A
Rationale: HIV can be transmitted from a mother to her baby during childbirth or breastfeeding, making choice A the correct answer. Tears, human bites, and insect bites are not common modes of HIV transmission. While human bites can potentially transmit the virus, it is less common compared to mother-to-child transmission.
A client reports being able to swallow only small bites of solid food and liquids for the last 3 months. The PN should assess the client for what additional information?
- A. Past traumatic injury to the neck
- B. Daily consumption of hot beverages
- C. History of alcohol or tobacco use
- D. Daily dietary intake of roughage
Correct Answer: C
Rationale: The correct answer is C: History of alcohol or tobacco use. A history of alcohol or tobacco use is significant as both are risk factors for esophageal cancer or other esophageal disorders that could cause difficulty swallowing (dysphagia). This information helps in evaluating the underlying cause of the symptom. Choices A, B, and D are less relevant in this context. While a past traumatic injury to the neck could potentially cause swallowing difficulties, given the chronic nature of the symptom in this case, it is more important to focus on potential risk factors associated with esophageal disorders like alcohol and tobacco use. Daily consumption of hot beverages and daily dietary intake of roughage are less likely to be directly related to the client's current swallowing issue.
Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?
- A. I don't have any use for those who say the disease is going to win
- B. I've found the support I need from my faith and family
- C. I think I've had this disease for a long time, but the doctor did not find it
- D. I understand that this is a disease that occurs mostly in older men
Correct Answer: B
Rationale: The correct answer is B because finding support in faith and family is a common way for individuals to cope with serious illnesses and come to terms with their prognosis. This statement indicates that the client has found a source of strength and comfort to deal with their situation. Choice A reflects defiance rather than acceptance. Choice C suggests denial or disbelief in the diagnosis. Choice D shows factual knowledge about the disease but does not necessarily indicate acceptance of the prognosis.
A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?
- A. Take all prescribed antibiotics as directed.
- B. Avoid crowded places and people who are sick.
- C. Wash hands frequently and practice good hygiene.
- D. Keep the surgical site clean and dry.
Correct Answer: C
Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (Choice A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (Choice B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (Choice D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.