Nokea
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect
- B. Most antipsychotic drugs cause elevated blood pressure
- C. This provides information on the amount of sodium allowed in the diet
- D. It will indicate the need to institute antiparkinsonian drugs
Correct Answer: A
Rationale: Orthostatic hypotension is a common side effect. Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after receiving medication. They should be advised to get up slowly, especially from a supine position.
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Which of these food choices, if selected by a client with diarrhea, would indicate the need for further teaching about dietary management?
- A. orange juice
- B. tuna
- C. eggs
- D. macaroni
Correct Answer: A
Rationale: Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.
An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?
- A. Add a thickening agent to the fluids
- B. Check the client's gag reflex
- C. Feed the client only solid foods
- D. Increase the rate of intravenous fluids
Correct Answer: B
Rationale: Check the client's gag reflex. When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.
A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?
- A. Sodium
- B. Potassium
- C. Phosphate
- D. Albumin
Correct Answer: B
Rationale: Potassium. If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as Aldactone should be administered because it inhibits the action of aldosterone on the kidneys.
The nurse provides a collection container to the client for collecting a sputum specimen for culture and sensitivity. Which additional interventions should the nurse implement? Select all that apply.
- A. Tell the client to spit into the container 2 to 3 times during the day.
- B. Wear gloves and protective eyewear when handling the specimen.
- C. After collection, place the sealed container in a clean plastic bag.
- D. Place a biohazard alert symbol on the bag containing the specimen container.
- E. Send the specimen to the laboratory within 30 minutes of collection.
Correct Answer: C,D,E
Rationale: C: A clean bag prevents external contamination. D: A biohazard symbol indicates infectious material. E: Prompt delivery ensures accurate results. A: Single morning collection is preferred. B: Eyewear is unnecessary.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.