The nurse is caring for a patient with chronic liver failure. Which medication order should the nurse question?
a. Lactulose
b. Neomycin
c. Multivitamins
d. Acetaminophen
ANS: D
Acetaminophen (Tylenol) overdose is the most common cause of ALF. Acetaminophen should not exceed 3000 mg in a 24 hour period. A. B. C. Multivitamins, Lactulose, and Neomycin are all used to treat symptoms of liver disease.
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The nurse administers a medication to a patient. Shortly afterward, the patient develops an itchy rash all of his body and reports feeling very unwell. What is the priority action of the nurse?
a. Leave the patient to notify the physician and the pharmacist. b. Determine if the patient is having any difficulty breathing. c. Document the reaction in the patient's chart. d. Obtain an order for hydrocortisone cream to relieve the itching.
To decrease disorientation during the detoxification period, the nurse should:
a. place the patient in a room with another recovering patient. b. instruct the patient to orient himself to his surroundings at bedtime. c. wake the patient up every 4 hours to eat a small snack. d. use nightlights and remove extra furniture from the room.
The nurse is reviewing the principles of family-centered care with a primipara. Which client statement will the nurse need to correct?
a. "Remaining focused on my family will help benefit me and my baby." b. "Most of the time, childbirth is uncomplicated and a healthy event for the family." c. "Because childbirth is normal, after my baby's birth our family dynamics will not change." d. "With correct information, I am able to make decisions regarding my health care while I am pregnant."
Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old partial-thickness wound?
a. Ensure that the client is systemically oxy-genated. b. Restrict the client's movement with bedr-est. c. Cover the wound with an airtight dressing. d. Apply hydrocortisone cream as ordered.