Nokea
Which statement by a client with acute renal failure indicates understanding of dietary restrictions?
- A. I will avoid oranges.
- B. I can eat unlimited protein.
- C. I should drink less water.
- D. I will eat more spinach.
Correct Answer: A
Rationale: Oranges are high in potassium, which should be avoided in acute renal failure.
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What is the nurse's best action for a client with a C6 spinal cord injury?
- A. Assess respiratory status.
- B. Check bladder function.
- C. Monitor skin integrity.
- D. Evaluate motor strength.
Correct Answer: A
Rationale: Assessing respiratory status is the priority due to potential diaphragmatic impairment in a C6 injury.
The nurse is caring for a client with herpes simplex virus who is experiencing an outbreak. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe?
- A. Metronidazole
- B. Acyclovir
- C. Imiquimod
- D. Fluconazole
Correct Answer: B
Rationale: Acyclovir is an antiviral medication used to treat herpes simplex virus (HSV) infections. Choice A (metronidazole) is used for bacterial and parasitic infections, Choice C (antibiotic) is for topical treatment of genital warts, and Choice D (fluconazole) is an antifungal for yeast infections.
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical.
The nurse is observing a nursing student prepare to give an intramuscular (IM) injection in a client's deltoid. Which action by the student requires follow-up?
- A. Depresses the plunger of the syringe during the insertion of the needle
- B. Locates the injection site 3 finger widths below the acromion process
- C. Positions the client either lying or sitting position
- D. Dons clean gloves before administering the injection
Correct Answer: A
Rationale: Depressing the plunger during needle insertion can cause medication to leak into subcutaneous tissue, leading to improper administration and potential tissue damage.
A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply.
- A. Mailing eye examinations every 6 months.
- B. Maintaining follow-up monitoring of liver enzymes.
- C. Decreasing protein intake in the diet.
- D. Avoiding alcohol intake.
- E. The urine may have an orange color.
Correct Answer: B,D,E
Rationale: Rifampin requires liver enzyme monitoring (B) and alcohol avoidance (D) due to hepatotoxicity risk. Orange urine (E) is a harmless side effect. Eye exams and reduced protein intake are not indicated.