Questions with Answers and Explanation
• The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which
... [Show More] laboratory value might indicate a serious side effect of this drug?
A. Uric acid of 5mg/dL
B. Hematocrit of 33%
C. WBC 2,000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter
Answer C: Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore, answers A, B, and D are incorrect.
• A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
A. “Tell me about his pain.”
B. “What does his vomit look like?”
C. “Describe his usual diet.”
D. “Have you noticed changes in his abdominal size?”
Answer C: The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incorrect.
• The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C: The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
• A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
A. Teaching how to irrigate the illeostomy
B. Stopping electrolyte loss in the incisional area
C. Encouraging a high-fiber diet
D. Facilitating perineal wound drainage
Answer D: The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time [Show Less]