A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

Correct Answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

Correct Answer: C

Rationale: Administering potassium via IV bolus is a high-risk procedure that requires careful attention and adherence to established protocols to prevent serious complications like cardiac arrest. Errors in administering IV medications, especially potent ones like potassium, can lead to severe harm to the patient and potential legal consequences for the healthcare provider. Therefore, including this example in the in-service on malpractice issues helps emphasize the importance of safe medication administration practices and the potential implications of errors.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Avocados. Phenelzine is a monoamine oxidase inhibitor (MAOI), a type of antidepressant medication. MAOIs interact with tyramine, a compound found in certain foods, leading to a potentially dangerous increase in blood pressure known as a hypertensive crisis. Avocados, along with other foods like aged cheeses, cured meats, and certain fish, contain high levels of tyramine, making them unsafe to consume while taking MAOIs like phenelzine. Regarding the incorrect options: A) Whole grain bread: Whole grain bread does not contain high levels of tyramine, so it is safe to eat while taking phenelzine. C) Smoked salmon: Like avocados, smoked salmon is high in tyramine, making it unsafe to consume with MAOIs. D) Pepperoni pizza: Pepperoni is a processed meat that is high in tyramine, so consuming it while on phenelzine can lead to a hypertensive crisis. Educationally, understanding drug-food interactions is crucial for nurses to ensure patient safety. Teaching patients about dietary restrictions while taking specific medications like MAOIs helps prevent adverse reactions and promotes optimal therapeutic outcomes. Nurses play a vital role in educating patients about medication management, including important considerations like dietary restrictions, to enhance patient compliance and well-being.

Correct Answer: D

Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.

Correct Answer: B

Rationale: In a client with left homonymous hemianopsia, there is a loss of vision on the right side of both eyes. Placing the bedside table on the right side of the bed ensures that essential items are within the client's field of vision, minimizing the risk of injury or accidents. Teaching the client to scan to the right and orienting them using the clock method may be helpful strategies, but placing the bedside table on the right side of the bed is a more direct and immediate intervention to enhance the client's safety and independence.