A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
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Solution
Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective.
Options A, C, and D: There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase.
The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
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Solution
The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line.
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
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Solution
Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly.
Option B: Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting.
Options C and D: Drinking more liquids and avoiding crowds is not necessary.
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to AVOID eating:
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Solution
Fresh raw or whole pepper are not allowed unless thoroughly cooked in food.
Option A: Canned fruits are allowed since they are processed and pasteurized.
Options B and D: Salt, ketchup, and sugar are allowed.
A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:
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Solution
During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and anastomosed.
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates an understanding of phantom limb pain?
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Solution
Pain related to phantom limb syndrome is due to peripheral nervous system interruption.
Option A is incorrect because phantom limb pain can last several months or indefinitely.
Option C is incorrect because it is not psychological.
Option D: It is also not due to infections.
A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?
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Solution
The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important.
Options A and B: The door should remain closed, but a negative-pressure room is not necessary. MRSA is spread by contact with blood or body fluid or by touching the skin of the client.
Option C: It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask.
During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?
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Solution
The client who is immunosuppressed and is exposed to measles should be treated with medications to boost his immunity to the virus.
Options A, C, and D: An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:
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Solution
Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood.
Options A, B, and C: It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
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Solution
Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent
Options B, C, and D: It does not prevent the formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity.