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Which instruction should the nurse include in the discharge teaching plan for an
adult client
with hypernatremia?
a. Monitor daily urine output volume
b. Drink plenty of water whenever thirsty
c. Use salt tablets for sodium content
d. Review food labels for sodium content - ANSWER -d
Hypernatremia is when a patient has a Sodium level that is too high, therefore it is
most
appropriate to teach the patient to check sodium levels on food labels before
discharging. (A)
While a high sodium level can decrease urine output, it is most important for the
patient to be
able to identify high sodium foods to decrease the risk of developing
hypernatremia again. (B)
Drinking too much water when thirsty can cause hyponatremia. (C) is incorrect
because the
patient is already at risk for developing high sodium levels again
While changing a client's post-operative dressing, the nurse observes a red and
swollen
wound with a moderate amount of yellow and green drainage and a foul odor.
Given there is a
positive MRSA, which is the most important action for the nurse to take?
A.
Force oral fluids
B.
Request a nutrition consult
,C.
Initiate contact precautions
D.
Limit visitors to immediate family only - ANSWER -c
MRSA is a type of antibiotic resistant bacteria and a patient with this should be
placed on contact
precautions. (A) oral fluids will not help rid the patient of the infection. (B) nor
nutrition. (D)
limiting visitors to immediate family is not necessary as anyone is at risk for
contracting MRSA
from an infected wound.
To prepare a client for the potential side effects of a newly prescribed medication,
what
action should the nurse implement?
a. Assess the client for health alterations that may be impacted by the effects of the
medication
b. Teach the client how to administer the medication to promote the best
absorption
c. Administer a half dose and observe the client for side effects before
administering a full
dosage
d. Encourage the client to drink plenty of fluids to promote effective drug
distribution - ANSWER -a
Before a new medication is given, an initial assessment should be completed to
create a baseline
for the patient; then the RN will be able to re-evaluate the patient and see if there
have been any
health alterations caused by the new medication. (B) this has nothing to do with
potential side
effects. (C) You should always administer a new medication as prescribed by the
MD. (D) The
amount of fluids the patient drinks will not affect the drug distribution in the body
, A client is 2 days post-op from a thoracic surgery and is complaining of incisional
pain. The
client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10
scale. After
calling the provider, what is the nurse's next action?
a. Instruct the client to use guided imagery and slow rhythmic breathing
b. Provide at least 20 minutes of back massage and gentle effleurage
c. Encourage the client to watch TV.
d. Place a hot water circulation device, such as an Aqua K pad, to operative site -
ANSWER -a
If there are no other PRN pain medications available after an initial dose was
given, it is most
appropriate to call the provider, then switch to alternative pain management
methods; like guided
imagery and encouraging slow rhythmic breathing. (B) while massage may be
helpful, it is
inappropriate for incisional pain as it may open the sutures. (C) While distraction
can help reduce
pain, watching TV does not rid the patient of the pain. (D) NEVER place a
circulation device on
an operative site as it may open the sutures!
A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The
pharmacy
provides 20 mg tablets. How many tablets should the client receive each day?
[Enter numeric
value only] - ANSWER -4 tablets
40 mg BID (BID is 2 times a day). So 40mg x 2 = 80mg/day.
80 mg day/20mg tablets available = 4 tablets a day.
An older adult male client is admitted to the medical unit following a fall at home.
When
undressing him, the nurse notes that he is wearing an adult diaper and skin
breakdown is obvious
over his sacral area. What action should the nurse implement first?