The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:
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Solution
Answer B is correct. The nurse should be concerned with alleviating the client’s pain. Answers A, B, and C are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.
A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
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Solution
Answer C is correct. Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Answers A, B, and C are not associated with Pulmozyme; therefore, they are incorrect.
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:
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Solution
Answer B is correct. The Whipple procedure is performed for cancer located in the head of the pancreas. Answers A, C, and D are not correct because of the location of the cancer.
The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms?
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Solution
Answer D is correct. Symptoms associated with diverticulitis are usually reported after eating popcorn, celery, raw vegetables, whole grains, and nuts. Answers A, B, and C are incorrect because they are allowed in the diet of the client with diverticulitis.
A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
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Solution
Answer A is correct. The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Answer B is incorrect because fever is not associated with atopic dermatitis. Answers C and D are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis.
A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
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Solution
Answer C is correct. The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Answers A, B, and D, common in the child with leukemia, are not life-threatening.
A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
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Solution
Answer D is correct. The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Answers A, B, and C are incorrect because they are permitted in the client’s diet.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
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Solution
Answer C is correct. The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Answers A, B, and D are not appropriate.
What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
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Solution
Answer B is correct. Solid foods should be added to the diet one at a time, with 4- to 7-day intervals between new foods. The extrusion reflex fades at 3–4 months of age; therefore, answer A is incorrect. Answer C is incorrect because solids should not be added to the bottle and the use of infant feeders is discouraged. Answer D is incorrect because the first food added to the infant’s diet is rice cereal.
Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
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Solution
Answer C is correct. The medication should be withheld and the doctor should be notified. Answers A, B, and D are incorrect because they do not provide for the client’s safety.