The physician has ordered a paracentesis for a client with severe ascites. Before the procedure, the nurse should:
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Solution
Answer A is correct. The client should void before the paracentesis to prevent accidental trauma to the bladder. Answer B is incorrect because the abdomen is not shaved. Answer C is incorrect because the client does not need extra fluids, which would cause bladder distention. Answer D is incorrect because the physician, not the nurse, would request an x-ray, if needed.
A client is admitted to the emergency room with partial-thickness burns of his head and both arms. According to the Rule of Nines, the nurse calculates that the TBSA (total body surface area) involved is:
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Solution
Answer B is correct. According to the Rule of Nines, the arms (18%) + the head (9%) = 27% TBSA burn injury. Answers A, B, and D are inaccurate percentages for the TBSA; therefore, they are incorrect.
The nurse is providing dietary teaching regarding low-sodium diets for a client with hypertension. Which food should be avoided by the client on a low-sodium diet?
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Solution
Answer D is correct. The client should avoid eating American and processed cheeses such as Colby and Cheddar because they are high in sodium. Dried beans, peanut butter, and Swiss cheese are low in sodium; therefore, answers A, B, and C are incorrect.
A client with myasthenia gravis is admitted with a diagnosis of cholinergic crisis. The nurse can expect the client to have:
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Solution
Answer A is correct. Cholinergic crisis is the result of overmedication with anticholinesterase inhibitors. Clients with cholinergic crisis have the following symptoms: nausea, vomiting, diarrhea, blurred vision, pallor, decreased blood pressure, and pupillary meiosis. Myasthenia crisis is the result of under medication with cholinesterase inhibitors. Answers B, C, and D are incorrect because they are symptoms of myasthenia crisis.
The nurse is applying a Transderm Nitro (nitrogycerin) patch to a client with angina. When applying the patch, the nurse should:
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Solution
Answer D is correct. Transderm Nitro is a reservoir patch that releases the medication via a semipermeable membrane. Cutting the patch allows too much of the drug to be released. Answer A is incorrect because the area should not be shaved because it can cause skin irritation. Answer B is incorrect because the skin is cleaned with soap and water. Answer C is incorrect because the patch is not covered with plastic wrap.
A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
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Solution
Answer A is correct. Adverse reactions to Thorazine include dystonia. Spasms of the neck and difficulty swallowing can lead to airway compromise. Answers B, C, and D are expected side effects that occur with the use of Thorazine. They do not require that the physician be notified immediately; therefore, they are incorrect.
The nurse is caring for a client with a long history of bulimia. The nurse would expect the client to have:
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Solution
Answer B is correct. The client with bulimia is prone to dental caries due to erosion of the tooth enamel from frequent bouts of self-induced vomiting. Answers A, C, and D are findings associated with anorexia nervosa, not bulimia; therefore, they are incorrect.
The physician has instructed the client with gout to avoid protein sources of purine. Which protein source is high in purine?
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Solution
Answer A is correct. Foods high in purine include dried beans, peas, spinach, oatmeal, poultry, fish, liver, lobster, and oysters. Answers B, C, and D are incorrect because they are low in purine. Other sources low in purine include most vegetables, milk, and gelatin.
A client tells the nurse that she takes St. John’s wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
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Solution
Answer B is correct. St. John’s wort has properties similar to those of monoamine oxidase inhibitors (MAOI). Eating foods high in tryramine (aged cheese, chocolate, salami, liver, and so on) can result in a hypertensive crisis. Answer A is incorrect because it can relieve mild to moderate depression. Answer C is incorrect because use of a sunscreen prevents skin reactions to sun exposure. Answer D is incorrect because the use of St. John’s wort decreases the amount of medication needed.
A client with rheumatoid arthritis is being treated with daily steroid medication. Which food should the client avoid?
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Solution
Answer A is correct. Persons receiving steroids should eat only cooked or processed foods. Raw oysters carry hepatitis A as well as E. coli. Answers B, C, and D are all suitable foods for the client taking steroid medication; therefore, they are incorrect.