The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication?
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Solution
Answer A is correct. The infant with tetrology of falot has five heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client, so answers B, C, and D are incorrect.
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
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Solution
Answer D is correct. The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer A is incorrect because turning the client to the left side will not help. Milking the tube is done only with an order and will not help in this situation, so answer B is incorrect. Slowing the intravenous infusion is inappropriate. The infusion should be increased, so answer C is incorrect.
The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:
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Solution
Answer A is correct. The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Answer B is not enough action. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Answer D is incorrect because asking the doctor to suture the tracheotomy in place is not appropriate.
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
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Solution
Answer B is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth. Answer A is incorrect because using oils and cream-based soaps is allowed. Answer C is incorrect because the client can eat salt. An electric razor is the best way to shave, so answer D is incorrect.
A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:
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Solution
Answer B is correct. Clients with a history of streptococcal infections might have antibodies that render the streptokinase ineffective. Answer A is incorrect because 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, so answer C is incorrect. A history of alcohol abuse is also not a factor in the order for streptokinase, so answer D is incorrect.
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
Answer A is correct. The client having removal of a central venous catheter should be told to hold his breath and bear down. This is known as the Valsalva maneuver. This prevents air from entering the line. Answers B, C, and D are incorrect because they will not facilitate removal.
A client is discharged home with a prescription for Coumadin (warfarin sodium). The client should be instructed to:
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Solution
Answer A is correct. Coumadin (sodium warfarin) is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Answer B is incorrect because eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K that increases clotting. Answer C is incorrect because drinking more liquids is not necessary. Answer D is not correct because avoiding crowds is also 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
Answer C is correct. Pepper is not processed and contains bacteria. Answer A is incorrect because fruits can be eaten; they should be cooked or washed and peeled. Answers B and D 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
Answer A is correct. During a Whipple procedure, the head of the pancreas, a portion of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and the esophagus also is not removed, as in answer D.
A client with an above-the-knee amputation is being taught methods to prevent hip-flexion deformities. Which instruction should be given to the client?
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Solution
Answer B is correct. To prevent hip-flexion deformities, the client should be instructed to lie prone every 4 hours for 30 minutes during the day. This will force the leg to extend to 0 and prevent the contracture. Answer A, C, and D are incorrect because lying on his back or side, or flat will not help.