Nursing Elites

1. A client with depression reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudoparkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: When St. John's wort, an herbal supplement, is taken with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of serotonin syndrome. Serotonin syndrome is a serious condition that can occur when there is an excess of serotonin in the body, leading to symptoms such as confusion, hallucinations, rapid heart rate, increased body temperature, and more. Monitoring for serotonin syndrome is crucial when these substances are taken together to prevent any potential harm to the client.

2. A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?

• A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
• B. ''I need to avoid drinking fluids if I develop symptoms.''
• C. ''I need a flu shot every 2 years because of the different flu strains.''
• D. ''I should cover my mouth with my hand when I sneeze.''

Correct answer: A

Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.

3. A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?

• A. Take quick breaths upon inhalation.
• B. Place your hand over your stomach.
• C. Take a deep breath in through your nose.
• D. Puff your cheeks upon exhalation.

Correct answer: C

Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.

4. When preparing to administer an IM injection that is irritating to the subcutaneous tissue, what is the best action to prevent tracking of the medication?

• A. Use a small gauge needle
• B. Apply ice on the injection site
• C. Administer at a 45° angle
• D. Use the Z-track technique

Correct answer: D

Rationale: The Z-track technique is the best action to prevent tracking of the medication when administering an IM injection that is irritating to the subcutaneous tissue. This technique involves pulling the skin to the side before administering the injection and then releasing the skin after the injection. By doing so, a zig-zag pathway is created, preventing the medication from leaking into the subcutaneous tissue and reducing irritation. Options A, B, and C are incorrect. Using a small gauge needle may not prevent tracking of the medication. Applying ice on the injection site or administering at a 45° angle does not specifically address preventing tracking of the medication in cases where the injection is irritating to the subcutaneous tissue.

5. When caring for a client who speaks a language different from their own, what action should the nurse take?

• A. Request an interpreter of a different sex from the client.
• B. Request a family member or friend to interpret information for the client.
• C. Direct attention toward the interpreter when speaking to the client.
• D. Review the facility policy about the use of an interpreter.

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

Similar Questions