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Questions 158

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Extract:


Question 1 of 5

The nurse is teaching a client with a history of chronic sinusitis about self-care. The nurse should tell the client to:

Correct Answer: A

Rationale: A humidifier keeps nasal passages moist, reducing irritation and promoting drainage in chronic sinusitis.

Question 2 of 5

An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?

Correct Answer: D

Rationale: When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. Disulfiram works on the classical conditioning principle. The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued.

Question 3 of 5

A client is admitted to the emergency department with a loss of consciousness with unknown etiology. The nurse expects to perform which laboratory test to assist in determining etiology?

Correct Answer: C

Rationale: Serum glucose is critical to rule out hypoglycemia or hyperglycemia as causes of unconsciousness. Cholesterol (
A), alkaline phosphatase (
B), and urinalysis (
D) are less urgent.

Question 4 of 5

Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:

Correct Answer: D

Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.

Question 5 of 5

A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:

Correct Answer: A

Rationale: The discomfort of photophobia is alleviated by dimming the lights. Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.

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