Nokea
Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?
- A. Direct sunlight
- B. Foods containing tyramine
- C. Foods fermented with yeast
- D. Canned citrus fruit drinks
Correct Answer: A
Rationale: Chlorpromazine increases photosensitivity, so direct sunlight should be avoided.
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Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include:
- A. Elevated RBC and elevated respiratory rate.
- B. Elevated WBC and elevated temperature.
- C. Elevated erythrocyte sedimentation rate and decreased pulse.
- D. Decreased platelets and decreased blood pressure.
Correct Answer: B
Rationale: Elevated white blood cell (WBC) count and fever are classic signs of infection. These indicators suggest the body is mounting an immune response to a potential pathogen.
A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?
- A. Rifampin
- B. Isoniazid
- C. Acyclovir
- D. Pyrazinamide
Correct Answer: C
Rationale: The correct answer is C: Acyclovir. Acyclovir is an antiviral medication used to treat herpes infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all first-line drugs for tuberculosis treatment. Rifampin is a bactericidal agent, Isoniazid disrupts mycobacterial cell wall synthesis, and Pyrazinamide targets actively replicating bacteria. Therefore, the nurse should not plan to administer Acyclovir as it is not indicated for tuberculosis treatment.
Tom is diagnosed with congestive heart failure and asks why fluid accumulates in his lungs. You respond by saying
- A. Because of the excessive volume of IV fluid that is being administered.
- B. The right side of your heart is weakened and is losing the capability to pump blood to your lungs.
- C. You stand too long at work.
- D. The left side of your heart is weakened and is losing the capability to pump blood to your lungs.
Correct Answer: D
Rationale: Left-sided heart failure leads to pulmonary congestion as blood backs up in the lungs.
Which nursing intervention minimizes disturbed sleep patterns in a dying client?
- A. Play the client’s favorite music.
- B. Mask the continuous hum of equipment.
- C. Provide a glass of warm milk before bed.
- D. Shut doors and windows to prevent noise from coming in.
Correct Answer: B
Rationale: Masking disruptive noises creates a more restful environment, promoting better sleep.
What action should the nurse include in teaching Mr. Ross about skin care of the irradiated area?
- A. Applying ointment or lotion to the skin
- B. Washing the area with soap and water
- C. Keeping the area dry and open to air
- D. Massaging the area and exposing it to sunlight
Correct Answer: C
Rationale: Protecting the skin from irritation and moisture promotes healing.