NCLEX- PN Practice Exam 7

EXPLANATION

✔ Correct answer:

2 capsules. To determine the correct number of capsules Nurse Lisa should administer, follow these steps:

1. Convert grams to milligrams, since the available medication is in milligrams:

- 0.2 g = 200 mg (since 1 g = 1000 mg).

2. Identify the dosage per capsule:

- Each capsule contains 100 mg of phenytoin.

3. Calculate the required number of capsules:

- 200 mg ÷ 100 mg/capsule = 2 capsules

Therefore, Nurse Lisa should administer 2 capsules in the morning.

Imagine you need 200 mg of a supplement, but each pill contains only 100 mg. To reach the required dose, you would take 2 pills. The same logic applies to medication calculations.

When administering phenytoin, Nurse Lisa should consider the following:

• Administer phenytoin at the same time each day to maintain therapeutic drug levels.
• Monitor for signs of phenytoin toxicity, including nystagmus, ataxia, confusion, and slurred speech.
• Educate the patient about oral hygiene, as phenytoin can cause gingival hyperplasia.
• Encourage routine blood level monitoring, as phenytoin has a narrow therapeutic range (10-20 mcg/mL).
• Administer with food to reduce gastrointestinal upset but avoid giving with tube feedings, as this can interfere with absorption.

✘ Incorrect answer options:

1 capsule: Incorrect—1 capsule provides only 100 mg, which is half of the prescribed 200 mg dose.

3 capsules: Incorrect—3 capsules would provide 300 mg, which exceeds the prescribed dose and could lead to toxicity.

4 capsules: Incorrect—4 capsules would provide 400 mg, which is double the prescribed dose and could cause serious side effects.

EXPLANATION

✔Correct answer:

Fresh specimens are necessary for reliable test results. Cytomegalovirus (CMV) is a herpesvirus that can cause significant illness, particularly in immunocompromised individuals and newborns. When collecting specimens for CMV cultures, fresh samples are essential to ensure the viability of the virus and the accuracy of the test results. Since CMV is a fragile virus, delays in processing or improper storage can lead to false-negative results.

Different types of specimens may be collected depending on the clinical presentation, including blood, urine, throat swabs, cerebrospinal fluid (CSF), or tissue samples. However, regardless of the sample type, ensuring it is fresh and transported promptly to the laboratory is critical for an accurate diagnosis.

 Imagine trying to check if a fruit is fresh. If you test it right away, you get an accurate idea of its ripeness. But if you leave it out too long, it may rot or change, giving misleading results—just like how CMV needs to be tested with fresh samples to avoid incorrect results.

Nurse Sophia should ensure proper specimen collection, handling, and transport to maximize test accuracy.

• Collect specimens as soon as possible after the order is placed to minimize viral degradation.
• Ensure specimens are stored properly (e.g., refrigerated if necessary) before transport to maintain viral integrity.
• Use appropriate personal protective equipment (PPE) to prevent the spread of CMV, especially to immunocompromised patients.
• Educate at-risk patients (e.g., pregnant individuals, organ transplant recipients, immunocompromised patients) about CMV transmission and prevention.
• Confirm with the laboratory regarding specific handling instructions to optimize sample viability.

✘Incorrect answer options:

Stool cultures are the preferred method for definitive diagnosis. While CMV can be detected in stool, it is not the preferred method for diagnosis. Blood, urine, throat swabs, and tissue biopsies are more commonly used, depending on the suspected site of infection.

Pregnant healthcare workers can safely collect CMV cultures. CMV is particularly concerning for pregnant individuals because it can cause congenital CMV infection, leading to severe complications in newborns, such as hearing loss, developmental delays, and neurological damage. Pregnant healthcare workers should avoid direct contact with potentially infectious body fluids and should follow strict infection control protocols.

A single specimen is enough for accurate diagnosis. CMV infections may require multiple specimens over time, particularly in congenital infections or immunocompromised patients, to confirm ongoing viral shedding or active infection. Repeated testing may be necessary for a definitive diagnosis.

EXPLANATION

✔Correct answer:

Supine with a sterile, moist dressing over the bladder. Bladder exstrophy is a rare congenital condition where the bladder develops outside the abdominal wall, leaving it exposed and vulnerable to infection, dehydration, and tissue damage. Immediate protection of the exposed bladder is crucial to prevent infection and preserve bladder integrity until surgical repair can be performed.

The best position for the newborn is supine (lying on their back) with a sterile, non-adherent, moist dressing covering the exposed bladder. This prevents drying and protects the delicate mucosa from contamination and trauma. The dressing should be moistened with sterile saline and changed regularly to prevent infection.

 Imagine an open wound that needs constant moisture to stay healthy. If left dry and exposed, it can crack and become infected. Keeping the bladder moist and covered prevents these complications until it can be surgically corrected.

Nurse Emily should take the following measures to ensure proper care and prevent complications:

• Position the newborn supine to prevent trauma to the exposed bladder.
• Cover the bladder with a sterile, moist, non-adherent dressing (moistened with sterile saline or sterile water) to prevent tissue drying and infection.
• Ensure strict aseptic technique when changing dressings to reduce the risk of infection.
• Monitor for signs of infection, such as redness, foul odor, or purulent drainage from the bladder mucosa.
• Keep the diaper positioned below the exposed bladder to prevent contamination from urine or feces.
• Prepare the newborn for surgical intervention, which is usually performed within the first few days of life.
• Provide parent education and emotional support, as this condition can be distressing for families. Encourage involvement in the newborn’s care.

✘Incorrect answer options:

Prone with a diaper loosely covering the exposed bladder. Placing the newborn prone (on their stomach) could put pressure on the exposed bladder, increasing the risk of damage and infection. Additionally, a diaper should not cover the bladder, as it may introduce contaminants.

Side-lying with the legs flexed toward the abdomen. This position does not provide adequate protection for the exposed bladder and increases the risk of friction or trauma. Supine positioning is preferred for better visibility, moisture retention, and sterility.

Trendelenburg position with the hips elevated. This position is not necessary for bladder exstrophy and could lead to respiratory compromise in the newborn. Supine positioning is the safest and most effective approach.

EXPLANATION

✔ Correct answer:

The patient’s urine is dilute, possibly indicating overhydration. Urine specific gravity measures the concentration of solutes in urine and reflects the kidney’s ability to concentrate or dilute urine. A normal specific gravity range is 1.010 to 1.030. A low specific gravity (≤1.006) suggests that the urine is dilute, which may be due to overhydration, diuretic use, or conditions such as diabetes insipidus.

The kidneys regulate fluid balance by adjusting urine concentration. When fluid intake is high or when the kidneys are unable to concentrate urine (as in diabetes insipidus), the urine becomes dilute, lowering the specific gravity. Overhydration (fluid overload) can lead to hemodilution, causing the kidneys to excrete excess fluid with a low specific gravity.

Imagine making lemonade. If you add too much water and not enough lemon juice, the drink becomes very weak. Similarly, when the kidneys excrete too much water, urine becomes overly diluted, lowering its specific gravity.

If a patient presents with a low urine specific gravity, Nurse Rachel should assess for signs of fluid overload and underlying conditions:

• Monitor for edema, weight gain, and hypertension, which may indicate fluid overload.
• Assess for neurological changes, such as confusion or headaches, which could suggest hyponatremia.
• Review the patient’s fluid intake and output (I&O) to detect imbalances.
• Evaluate for possible medication effects, such as diuretics, which can increase urine output.
• Check for conditions like diabetes insipidus, which causes excessive urination and dilute urine due to low antidiuretic hormone (ADH) levels.
• Collaborate with the healthcare provider to adjust fluid management if needed.

✘ Incorrect answer options:

The patient may be experiencing dehydration. Dehydration would lead to concentrated urine with a high specific gravity (>1.030), as the kidneys conserve water.

The patient has a normal urine concentration. A normal urine specific gravity falls between 1.010 and 1.030. A value of 1.006 is below this range, indicating dilution.

The patient may have a urinary tract infection (UTI). UTIs are often associated with cloudy urine, foul odor, and increased specific gravity due to the presence of bacteria, white blood cells, and proteins. A low specific gravity is not a primary indicator of a UTI.

EXPLANATION

✔ Correct answer:

Return the aspirate and proceed with the feeding. Gastric residual volume (GRV) assessment is an essential step before administering enteral feedings. The purpose is to evaluate gastric emptying and assess the risk of aspiration. Returning the aspirated contents prevents fluid and electrolyte imbalances, as gastric juices contain essential digestive enzymes and acids necessary for proper digestion. A residual volume of less than 250-500 mL is generally considered safe, so Nurse Daniel should return the aspirate and continue the feeding unless institutional policy states otherwise.

Patients with a cerebrovascular accident (CVA) are at an increased risk of dysphagia and aspiration due to impaired swallowing reflexes and reduced gastric motility. However, a small gastric residual (such as 40 mL) does not necessarily indicate delayed gastric emptying. Large residuals (typically greater than 250-500 mL on two consecutive checks) may indicate delayed gastric emptying and require further evaluation.

Think of the stomach as a reservoir that processes food before it moves into the intestines. If a small amount of liquid remains in a cup before refilling it, it does not mean the cup is full. Similarly, a small gastric residual is normal and should be returned to maintain proper digestion and prevent nutrient loss.

Proper nasogastric (NG) tube care and monitoring are crucial for ensuring patient safety and effective enteral feeding.

• Assess gastric residual volume per facility protocol (typically every 4-6 hours for continuous feedings or before each intermittent feeding).
• Return gastric aspirate unless residual volume is excessive (institutional threshold, often >250-500 mL).
• Monitor for signs of intolerance, such as abdominal distension, nausea, vomiting, or high residual volumes.
• Ensure proper NG tube placement before each feeding by checking pH (gastric pH is typically ≤5) and tube marking length.
• Maintain the patient in a semi-Fowler’s position (30-45 degrees) during and for at least 30-60 minutes after feeding to reduce aspiration risk.
• Document residual volume and patient response to feedings.

✘ Incorrect answer options:

Discard the aspirate and hold the feeding. Discarding gastric residual fluid can lead to electrolyte imbalance and loss of important digestive enzymes. Additionally, holding the feeding is unnecessary for a residual volume of only 40 mL.

Discard the aspirate and start the feeding. While the feeding should proceed, the aspirate should not be discarded. Returning the residual maintains gastric pH balance and prevents unnecessary fluid loss.

Return the aspirate and withhold the feeding. Since 40 mL is a small residual amount, withholding the feeding is not warranted. Delaying feedings without justification can lead to nutritional deficits and delayed recovery.

EXPLANATION

✔ Correct answer:

Diarrhea. Magnesium hydroxide is a common magnesium-based antacid that helps neutralize stomach acid and provide relief from heartburn, which is a common symptom in patients with a hiatal hernia. However, excessive use of magnesium-based antacids can cause osmotic diarrhea, as magnesium draws water into the intestines, stimulating bowel movements.

Magnesium hydroxide functions as both an antacid and an osmotic laxative. When taken in large amounts, it pulls excess water into the intestines, leading to looser stools and diarrhea. This can lead to dehydration and electrolyte imbalances if excessive diarrhea occurs.

Think of magnesium hydroxide like a sponge that absorbs water into the intestines. When too much is used, it overwhelms the digestive system, causing watery stools and diarrhea.

Nurse Alexis should educate the patient about the risks of excessive antacid use and recommend appropriate management strategies:

• Monitor for signs of electrolyte imbalances, such as weakness or irregular heartbeats, due to excessive diarrhea.
• Encourage moderation in antacid use and consider alternative treatments, such as H2-receptor blockers or proton pump inhibitors (PPIs) for long-term acid control.
• Assess for renal function, as magnesium accumulation can occur in patients with kidney disease, leading to toxicity.
• Encourage dietary modifications, such as avoiding spicy foods, caffeine, and large meals, to reduce heartburn symptoms naturally.
• Educate the patient on the differences between magnesium-based and aluminum- or calcium-based antacids, which can cause constipation instead of diarrhea.

✘ Incorrect answer options:

Constipation: Constipation is associated with aluminum- and calcium-based antacids, such as aluminum hydroxide or calcium carbonate (Tums), rather than magnesium-based antacids.

Weight gain: Magnesium hydroxide does not directly cause weight gain. It primarily affects the gastrointestinal tract rather than metabolism or fat storage.

Loss of appetite: While excessive diarrhea can lead to dehydration and general malaise, magnesium hydroxide does not directly cause appetite suppression.

EXPLANATION

✔ Correct answer:

The head circumference is about 2 cm larger than the chest. During a newborn assessment, measuring head and chest circumference is essential to monitor growth, neurological development, and potential abnormalities. In a healthy term neonate, the head circumference is typically 2 cm larger than the chest circumference at birth.

Normal Newborn Measurements:  

• Head circumference: 33–35 cm
• Chest circumference: 31–33 cm
• Expected difference: Head is about 2 cm larger than the chest at birth.

As the infant grows, the chest circumference catches up. By around 12 months of age, the head and chest circumferences are approximately equal.

The larger head size at birth is due to the rapid brain growth during fetal development. The brain undergoes significant growth in the first year of life, so a proportionally larger head is normal.

Imagine a balloon inflating inside a box—the balloon (brain) expands faster than the box (chest). Over time, the box grows to match the balloon’s size. Similarly, the chest grows and eventually catches up with head circumference.

When assessing newborn measurements, Nurse Lillian should:

• Use a non-stretchable measuring tape to ensure accuracy.
• Measure the head circumference at the widest part (just above the eyebrows and around the occipital prominence).
• Measure the chest circumference at the level of the nipple line.
• Monitor for abnormal head sizes:
  • Microcephaly (small head) may indicate genetic conditions or intrauterine growth restriction (IUGR).
  • Macrocephaly (large head) may suggest hydrocephalus or increased intracranial pressure.
• Educate parents that head-to-chest ratio normalizes by 1 year of age.

✘ Incorrect answer options:

The head and chest circumference are equal in size. The head circumference is typically larger than the chest at birth. They do not become equal until around 1 year of age.

The head circumference is approximately 3 cm smaller than the chest. A head smaller than the chest at birth is abnormal and may indicate microcephaly, intrauterine growth restriction (IUGR), or prematurity.

The head circumference is around 4 cm larger than the chest. A difference of 4 cm is more than expected and may indicate macrocephaly or conditions like hydrocephalus.

EXPLANATION

✔Correct answer:

The patient complains of a sore throat. Chlorpromazine is a first-generation (typical) antipsychotic used to manage schizophrenia and other psychiatric disorders. One of its rare but life-threatening side effects is agranulocytosis, a condition where the bone marrow significantly reduces white blood cell (WBC) production, increasing the risk of severe infections.

A sore throat can be an early sign of agranulocytosis, which may lead to life-threatening neutropenia and sepsis if untreated. Other symptoms include fever, chills, mouth ulcers, and flu-like symptoms. Because this condition can progress rapidly, any report of a sore throat in a patient taking chlorpromazine requires immediate reporting to the physician and a WBC count check.

 Think of the immune system as the body's security team. If the security team is weakened (due to low WBCs), harmful intruders (infections) can take over quickly. A sore throat in this case is like an early warning sign that the security system is failing.

Nurse Brian should act promptly to ensure the patient’s safety by implementing the following interventions:

• Immediately report the sore throat to the physician, as it may indicate agranulocytosis.
• Monitor for fever, chills, mouth ulcers, and other signs of infection.
• Obtain a complete blood count (CBC) with differential to check WBC and neutrophil levels.
• Educate the patient to report any signs of infection immediately, such as fever or persistent fatigue.
• Prepare for possible discontinuation of chlorpromazine if agranulocytosis is confirmed.
• Ensure infection control precautions if neutropenia is present.

✘Incorrect answer options:

The patient reports feeling thirsty. Increased thirst may indicate dry mouth, a common side effect of chlorpromazine due to its anticholinergic properties. While uncomfortable, this is not an urgent finding. Patients can be advised to increase fluid intake or use sugar-free gum to relieve dry mouth.

The patient has gained 4 pounds over two months. Weight gain is a known side effect of antipsychotic medications but does not require immediate intervention unless excessive or rapid. Regular monitoring and dietary counseling can help manage this effect.

The patient frequently naps throughout the day. Sedation is another common side effect of chlorpromazine. While excessive drowsiness may require medication adjustments, it is not an immediate concern like a sore throat indicating potential agranulocytosis.

EXPLANATION

✔ Correct answer:

It can interfere with normal bone growth. A femur fracture involving the epiphysis (growth plate) is particularly concerning because the growth plate is responsible for longitudinal bone growth. Damage to this area can lead to growth disturbances, resulting in limb length discrepancies or angular deformities.

The epiphyseal plate, also known as the growth plate, is a cartilaginous area located at the ends of long bones in children. It is a critical site for bone development and elongation. A fracture that disrupts this region can lead to premature closure of the growth plate or irregular bone growth. The Salter-Harris classification system is commonly used to categorize these fractures, with higher-grade fractures (Types III, IV, and V) carrying a greater risk of growth abnormalities.

Think of the growth plate as the foundation of a growing tree. If the foundation is damaged, the tree may grow unevenly or stop growing altogether. Similarly, an injured growth plate can lead to uneven bone development or stunted growth.

Since growth plate fractures can significantly impact a child's future bone development, appropriate care and follow-up are essential.

• Monitor for signs of impaired bone growth, such as limb length discrepancies or deformities.
• Educate parents about the importance of follow-up with an orthopedic specialist for long-term monitoring.
• Ensure immobilization of the fracture site to promote proper healing.
• Assess for pain and administer prescribed analgesics as needed.
• Encourage age-appropriate mobility and physical therapy once healing allows.

✘ Incorrect answer options:

Bone marrow may be lost at the fracture site. While fractures can cause some local marrow disruption, this is not the primary concern with epiphyseal fractures. The major issue is growth disturbance rather than significant marrow loss.

The blood supply to the bone is completely disrupted. While fractures can compromise local blood supply, a complete disruption is uncommon unless a severe injury affects the metaphyseal or diaphyseal regions. The primary concern with epiphyseal fractures is abnormal bone growth rather than total vascular disruption.

Callus formation can block proper bone healing. Callus formation is a natural part of the bone healing process. In most fractures, callus formation facilitates healing rather than obstructing it. The concern with epiphyseal fractures is more about abnormal bone growth rather than interference from callus formation.

EXPLANATION

✔Correct answer:

Tinnitus. Acute aspirin toxicity, also known as salicylism or salicylate poisoning, occurs when there is an excessive accumulation of salicylates in the body. One hallmark symptom of acute aspirin toxicity is tinnitus, which refers to a ringing or buzzing sensation in the ears. This occurs due to the ototoxic effects of high salicylate levels, which interfere with the function of the cochlea in the inner ear. Salicylates disrupt normal cellular metabolism and electrolyte balance, leading to symptoms such as tinnitus, hearing loss, hyperventilation, and metabolic acidosis. Monitoring for tinnitus is critical because it often precedes more severe complications, such as respiratory alkalosis and central nervous system disturbances.

Aspirin (acetylsalicylic acid) is metabolized in the liver and excreted by the kidneys. At therapeutic doses, aspirin inhibits cyclooxygenase enzymes, reducing inflammation, pain, and fever. However, at toxic levels, aspirin uncouples oxidative phosphorylation in mitochondria, leading to increased oxygen consumption, lactate production, and metabolic acidosis. The central nervous system becomes overstimulated, resulting in symptoms like tinnitus, confusion, and seizures.

Think of aspirin as a car engine running smoothly at low speeds (therapeutic dose). If you rev the engine too high (toxic dose), it starts making strange noises (tinnitus) and may eventually overheat (severe toxicity).

Nurses should be vigilant in monitoring patients on aspirin therapy, especially those receiving high doses for conditions like rheumatoid arthritis. Key interventions include:

• Assessing for early signs of aspirin toxicity, such as tinnitus, headache, nausea, and dizziness.
• Monitoring vital signs, including respiratory rate and depth, as hyperventilation is common in salicylate toxicity.
• Educating the patient about the importance of adhering to prescribed dosages and recognizing symptoms of toxicity.
• Collaborating with the healthcare provider to adjust dosages or discontinue aspirin if toxicity is suspected.
• In cases of confirmed toxicity, preparing for interventions such as activated charcoal administration, intravenous fluids, and bicarbonate therapy to correct acid-base imbalances.

✘Incorrect answer options:

Anorexia. While anorexia (loss of appetite) can occur with chronic aspirin use or mild toxicity, it is not a specific indicator of acute aspirin toxicity. Anorexia is a nonspecific symptom that could result from various causes, including gastrointestinal irritation or other systemic illnesses.

Diarrhea. Diarrhea is not a characteristic symptom of acute aspirin toxicity. Gastrointestinal upset, such as nausea and vomiting, is more commonly associated with aspirin use, but diarrhea is not a hallmark sign of toxicity.

Pruritus. Pruritus (itching) is unrelated to aspirin toxicity. It is more commonly associated with allergic reactions, dermatological conditions, or cholestatic liver disease rather than salicylate overdose.

EXPLANATION

✔Correct answer:

Gently pull the ear down and back. When administering ear drops to children under 3 years old, the pinna (outer ear) should be pulled down and back to straighten the ear canal and allow proper medication absorption. This positioning aligns the external auditory canal more effectively in young children because their ear canals are shorter and more horizontal compared to adults.

In contrast, for adults and children over 3 years old, the ear should be pulled up and back to properly straighten the canal.

 Think of a bent straw—if you try to pour liquid through it while it's curved, the liquid may not flow properly. Straightening the straw (ear canal) allows the liquid (ear drops) to go in smoothly and reach the affected area.

Nurse Hannah should ensure proper administration technique to maximize medication effectiveness and comfort for the child.

• Wash hands and wear gloves before administering the ear drops to prevent infection.
• Position the child comfortably, preferably lying on their side with the affected ear facing up.
• Gently pull the pinna down and back to straighten the ear canal.
• Administer the prescribed number of drops without touching the dropper to the ear to avoid contamination.
• Encourage the child to remain in position for at least 2-5 minutes to allow the medication to coat the ear canal properly.
• Gently massage the tragus (the small flap in front of the ear canal) to help distribute the medication.

✘Incorrect answer options:

Pull the ear straight outward. Pulling the ear outward does not effectively straighten the ear canal in young children, making it harder for the medication to reach the affected area.

Lift the ear up and back. This technique is used for adults and children over 3 years old, not for a 2-year-old. At this age, the ear canal remains more horizontal, requiring a down and back motion instead.

Leave the ear in its natural position. If the ear is left in its natural position, the ear canal remains curved, and the ear drops may not properly reach the infection site. Adjusting the ear canal alignment is essential for effective treatment.

EXPLANATION

✔Correct answer:

Reduce nausea. Ondansetron (Zofran) is an antiemetic that works by blocking serotonin (5-HT3) receptors in the brain and gastrointestinal tract. It is primarily used to prevent and manage nausea and vomiting caused by chemotherapy, radiation therapy, and postoperative conditions. Chemotherapy-induced nausea and vomiting (CINV) occur due to the release of serotonin from the small intestine, which stimulates the vomiting center in the brain. By blocking serotonin receptors, ondansetron helps prevent this response, making it highly effective in improving patient comfort and adherence to cancer treatment.

Ondansetron is typically administered 30 minutes before chemotherapy to provide optimal protection against early-onset nausea and vomiting. It can be given orally, intravenously, or as an orally disintegrating tablet (ODT) for patients who have difficulty swallowing.

Imagine your brain has an "alarm system" for nausea, triggered when serotonin levels rise. Ondansetron acts like a mute button, blocking the alarm before it can go off, preventing nausea and vomiting.

Nurse Emily should ensure proper administration and monitoring of ondansetron’s effectiveness.

• Administer ondansetron 30 minutes before chemotherapy to maximize its anti-nausea effect.
• Monitor the patient for common side effects, such as headache, dizziness, and constipation.
• Assess for electrocardiogram (ECG) changes, as ondansetron can cause QT prolongation, increasing the risk of arrhythmias.
• Educate the patient on the importance of hydration and dietary modifications to further reduce nausea.
• Collaborate with the healthcare team to adjust antiemetic therapy if breakthrough nausea occurs.

✘Incorrect answer options:

Help prevent anemia. Ondansetron does not affect red blood cell production or hemoglobin levels. Chemotherapy can cause anemia, but treatment usually involves erythropoiesis-stimulating agents (ESAs) or blood transfusions, not ondansetron.

Induce a state of relaxation. While ondansetron may improve patient comfort by reducing nausea, it does not have sedative or anxiolytic effects like benzodiazepines (e.g., lorazepam) or opioids.

Boost neutrophil production. Ondansetron has no effect on white blood cell or neutrophil production. Patients undergoing chemotherapy may develop neutropenia, which is treated with colony-stimulating factors (CSFs) like filgrastim (Neupogen) rather than antiemetics.

EXPLANATION

✔Correct answer:

Grilled chicken with steamed vegetables and brown rice. Gout is a type of inflammatory arthritis caused by elevated levels of uric acid in the blood, which can lead to the formation of monosodium urate crystals in joints, resulting in pain, swelling, and inflammation. Uric acid is a byproduct of purine metabolism, and foods high in purines can exacerbate gout symptoms. Therefore, dietary management focuses on reducing purine intake while maintaining a balanced diet. Grilled chicken, steamed vegetables, and brown rice are low in purines and represent an ideal meal for someone with gout. Chicken (in moderate portions) and most vegetables are considered low-purine foods, and brown rice provides complex carbohydrates without contributing to uric acid production.

Purines are naturally occurring compounds found in many foods, particularly meats, seafood, and some vegetables. When purines are metabolized, they break down into uric acid. In individuals with gout, either overproduction of uric acid or underexcretion by the kidneys leads to hyperuricemia. This excess uric acid crystallizes in joints, triggering an inflammatory response that causes acute gout attacks. Dietary modifications aim to minimize purine intake and reduce the frequency and severity of these attacks.

Managing gout through diet is like managing a leaky faucet. If too much water (purines) flows through the pipes (your body), it can overflow and cause damage (gout attacks). By turning down the flow (reducing purine intake), you prevent the overflow and keep things running smoothly.

Nurses play a key role in educating patients with gout about dietary choices to manage their condition effectively. Key interventions include:

• Encouraging the consumption of low-purine foods such as lean proteins (e.g., chicken, turkey), vegetables (except for high-purine options like spinach and asparagus), and whole grains.
• Advising the patient to limit or avoid high-purine foods, including red meat, organ meats, shellfish, and alcohol (especially beer).
• Recommending adequate hydration to promote uric acid excretion through urine.
• Educating the patient about portion control, as even moderate-purine foods can contribute to gout if consumed in large quantities.
• Collaborating with a registered dietitian to develop a personalized meal plan that aligns with the patient’s preferences and nutritional needs.

✘Incorrect answer options:

Grilled salmon with asparagus and quinoa. While this meal includes healthy components like quinoa and asparagus, salmon is a moderately high-purine food due to its richness in protein and nucleic acids. For individuals with gout, consuming fish like salmon should be done in moderation, making this option less suitable compared to grilled chicken.

Beef stew with mashed potatoes and gravy. Beef is a high-purine food, and consuming it can increase uric acid levels, potentially triggering a gout attack. Additionally, gravy often contains meat-based ingredients that further elevate purine content. This meal is not appropriate for someone managing gout.

Lentil soup with whole-grain bread. Lentils are legumes that contain moderate amounts of purines, and while they are nutritious, they may contribute to elevated uric acid levels if consumed frequently or in large portions. Whole-grain bread is acceptable, but this meal is not the best choice for a patient with gout compared to lower-purine options.

EXPLANATION

✔Correct answer:

6 liters per minute. When administering oxygen via a simple face mask, the flow rate must be set at a minimum of 5 to 6 liters per minute (L/min) to prevent the patient from rebreathing exhaled carbon dioxide (CO₂). At lower flow rates, CO₂ can accumulate inside the mask, leading to respiratory distress or hypercapnia.

The recommended oxygen flow rates for different delivery devices are:

• Nasal cannula: 1–6 L/min (FiO₂ 24%–44%)
• Simple face mask: 5–10 L/min (FiO₂ 40%–60%)
• Non-rebreather mask: 10–15 L/min (FiO₂ up to 90%)
• Venturi mask: Precise FiO₂ settings (24%–50%)

Since the physician ordered oxygen via mask, Nurse Jake should set the flow at 6 L/min or higher to ensure adequate oxygenation while preventing CO₂ buildup.

Imagine breathing inside a small plastic bag—without fresh air, CO₂ builds up quickly, making it harder to breathe. A simple face mask needs at least 5–6 L/min of fresh oxygen to flush out exhaled CO₂ and keep oxygen levels safe.

Nurse Jake should ensure safe and effective oxygen delivery while monitoring the patient’s respiratory status.

• Set the oxygen flow rate to at least 6 L/min when using a simple face mask to prevent CO₂ retention.
• Monitor oxygen saturation (SpO₂) using pulse oximetry and adjust the flow rate as needed.
• Assess for signs of hypoxia, including dyspnea, confusion, restlessness, and cyanosis.
• Evaluate for oxygen toxicity symptoms (e.g., dry cough, chest discomfort) in cases of prolonged high-flow oxygen therapy.
• If the patient has chronic obstructive pulmonary disease (COPD), use caution with high-flow oxygen and consider a Venturi mask for controlled FiO₂ delivery.

✘Incorrect answer options:

2 liters per minute. This flow rate is too low for a simple face mask and could cause CO₂ retention. A nasal cannula would be more appropriate at 2 L/min.

10 liters per minute. While 10 L/min is safe for a simple face mask, it may be unnecessary unless the patient requires a higher FiO₂. 6–10 L/min is the typical range.

12 liters per minute. This is excessive for a simple face mask and is more appropriate for a non-rebreather mask, which delivers nearly 100% oxygen.

EXPLANATION

✔ Correct answer:

Perform oral hygiene and gum care every shift. Phenytoin is an anticonvulsant commonly prescribed for seizure disorders. One of its most significant adverse effects is gingival hyperplasia, a condition characterized by overgrowth of gum tissue, which can lead to pain, bleeding, and an increased risk of infection if not properly managed. Regular oral hygiene and gum care help prevent this complication.

Phenytoin-induced gingival hyperplasia is more common in long-term therapy and in children or adolescents. Encouraging good oral hygiene, including brushing, flossing, and regular dental check-ups, is essential in preventing severe gum overgrowth.

Imagine a garden where the plants (gums) grow uncontrollably without regular trimming (oral care). Without maintenance, the plants overgrow and become difficult to manage, just like gums affected by phenytoin-induced hyperplasia. Regular "trimming" (oral hygiene) keeps them healthy.

Nurses play a crucial role in monitoring and educating patients on the proper management of phenytoin therapy. Important considerations include:

• Encourage regular oral hygiene, including brushing with a soft-bristled toothbrush and daily flossing.
• Educate the patient on the signs of gingival hyperplasia, such as swollen, bleeding gums, and encourage regular dental visits.
• Monitor for other phenytoin side effects, such as ataxia (loss of coordination), drowsiness, and nystagmus (involuntary eye movements).
• Assess serum phenytoin levels regularly to ensure therapeutic dosing (normal range: 10–20 mcg/mL).
• Warn the patient about drug interactions, as phenytoin has many interactions that can alter its effectiveness.
• Instruct female patients on contraceptive options, as phenytoin can reduce the effectiveness of oral contraceptives.

✘ Incorrect answer options:

Carefully monitor and document intake and output: While monitoring intake and output is essential for some medications, phenytoin does not primarily affect renal function or fluid balance. This intervention would be more relevant for drugs that impact kidney function, fluid retention, or electrolyte balance.

Assess the patient’s pulse before administering the medication: Unlike beta-blockers or calcium channel blockers, phenytoin does not directly affect heart rate. While it can cause cardiovascular effects at toxic levels, routine pulse assessment before administration is not a standard practice for this medication.

Give the medication 30 minutes before meals: Phenytoin can be given with or without food, but taking it with food helps reduce gastrointestinal irritation. The priority is maintaining a consistent administration schedule rather than strict timing in relation to meals.

EXPLANATION

✔Correct answer:

Baked apple slices with cinnamon. Acute glomerulonephritis is a kidney condition that impairs the organ's ability to properly filter waste, electrolytes, and fluids. Because potassium excretion may be compromised, patients are often placed on a low-potassium diet to prevent hyperkalemia, which can lead to dangerous cardiac complications such as arrhythmias.

Apples are naturally low in potassium, making them a suitable choice for a child on a restricted potassium diet. Baking the apple slices with cinnamon enhances their flavor without introducing additional potassium. This snack is both safe and enjoyable while adhering to dietary restrictions.

 Imagine the kidneys as a water filter. If the filter is damaged, certain substances (like potassium) can build up instead of being properly removed. Eating foods high in potassium when the filter is not working well can lead to an overload, similar to a clogged filter spilling out excess impurities into drinking water.

When caring for a child with acute glomerulonephritis, dietary modifications play a key role in managing electrolyte balance and preventing complications.

• Educate the parent and child on low-potassium food options, including apples, grapes, berries, rice, and pasta.
• Monitor the child’s serum potassium levels and report any signs of hyperkalemia, such as muscle weakness or irregular heart rhythms.
• Encourage hydration while following fluid restrictions if prescribed by the healthcare provider.
• Collaborate with a dietitian to develop a meal plan that meets the child’s nutritional needs while adhering to potassium restrictions.
• Teach parents how to read food labels to identify hidden sources of potassium, such as in dairy products, potatoes, and certain nuts.

✘Incorrect answer options:

Banana slices with peanut butter. Bananas are high in potassium, making them unsuitable for a low-potassium diet. Peanut butter also contains moderate amounts of potassium, further increasing the risk of exceeding dietary restrictions.

Orange wedges with yogurt dip. Oranges are a high-potassium fruit, and yogurt also contains potassium, making this snack inappropriate for a child on a potassium-restricted diet.

Mashed avocado on whole-grain toast. Avocados are extremely high in potassium, making them unsuitable for individuals with kidney dysfunction. Even small portions can contribute significantly to elevated potassium levels.

EXPLANATION

✔ Correct answer:

Burp the baby frequently throughout the feeding. Gastroesophageal reflux (GER) is a common condition in infants due to the immaturity of the lower esophageal sphincter (LES), which allows stomach contents to flow back into the esophagus. Frequent burping during feedings helps reduce reflux episodes by preventing air buildup in the stomach, which can contribute to regurgitation and discomfort.

In infants, the LES is still developing, making it easier for stomach contents to be pushed back into the esophagus. When a baby swallows air while feeding, this increases intra-abdominal pressure, which can further promote reflux. By burping the baby frequently, caregivers help release swallowed air, reducing pressure on the LES and minimizing regurgitation.

Imagine filling a bottle with liquid and shaking it—air bubbles form, creating pressure inside. If you slowly release the bubbles as you pour, there is less overflow. Similarly, burping an infant frequently helps release trapped air, preventing excessive pressure that can push milk back up.   

To help manage gastroesophageal reflux in infants, Nurse Jessica should educate the mother on proper feeding and positioning techniques.

• Encourage frequent burping—every 1 to 2 ounces during bottle feeding and between switching breasts during breastfeeding.
• Keep the baby upright for at least 20-30 minutes after feeding to reduce reflux episodes.
• Use smaller, more frequent feedings to avoid overdistension of the stomach.
• Advise parents to avoid placing the baby in a car seat immediately after feeding, as this can increase abdominal pressure.
• Educate caregivers on signs of severe GERD, such as poor weight gain, irritability, or frequent vomiting, which may require further medical evaluation.

✘ Incorrect answer options:

Feed the baby only when signs of hunger are present. While feeding on demand is generally encouraged, this does not directly prevent reflux. Instead, smaller, more frequent feedings are beneficial in reducing reflux symptoms.

Burp the baby only after finishing the entire feeding. Waiting until the end of the feeding allows air to build up in the stomach, increasing intra-abdominal pressure and the likelihood of reflux. Frequent burping throughout the feeding is more effective.

Position the baby supine with the head elevated. The supine position is recommended for safe sleep per the American Academy of Pediatrics (AAP) guidelines. However, elevating the head in the supine position is not advised, as it does not effectively reduce reflux and may lead to positional asphyxiation. Instead, keeping the baby upright after feedings is recommended.

EXPLANATION

✔Correct answer:

Mix the medication with 4 ounces of juice. Oral potassium supplements, such as potassium chloride (KCl), can cause significant gastrointestinal (GI) irritation, including nausea, vomiting, and esophageal ulceration. To minimize these adverse effects, potassium supplements should be diluted in a sufficient amount of liquid, such as juice or water, before administration. Mixing potassium with at least 4 to 8 ounces of juice (or another palatable liquid) not only helps prevent GI discomfort but also improves the taste, making it more tolerable for the patient.

 Think of concentrated potassium supplements like strong lemon juice. Drinking it straight can burn your throat, but diluting it with water or another liquid makes it safer and easier to swallow.

Nurse Daniel should take precautions to ensure safe administration of oral potassium supplements while minimizing patient discomfort.

• Always dilute liquid potassium supplements with at least 4 to 8 ounces of juice or water to reduce GI irritation.
• Administer potassium with food to further decrease the risk of nausea and gastric discomfort.
• Instruct the patient to drink the mixture slowly and avoid lying down for at least 30 minutes after taking the medication to prevent esophageal irritation.
• Monitor the patient for signs of hyperkalemia, such as muscle weakness, irregular heart rhythms, and paresthesia (tingling sensations).
• Ensure that potassium levels are monitored regularly, as excessive supplementation can lead to life-threatening arrhythmias.

✘Incorrect answer options:

Administer the medication without dilution. Potassium supplements should never be taken undiluted, as they can cause severe esophageal irritation, ulcers, and gastric distress.

Give the medication only with water. While water is an acceptable diluent, juice is preferred because it can mask the unpleasant taste of potassium supplements, improving patient compliance.

Administer the medication on an empty stomach. Taking potassium on an empty stomach increases the risk of gastric irritation, nausea, and vomiting. It should always be given with food or after meals to reduce these effects.

EXPLANATION

✔Correct answer:

27%

The Rule of Nines is a quick method used to estimate the total body surface area (TBSA) burned in adult patients. This method divides the body into sections, each representing a percentage of TBSA, as follows:

• Head and neck: 9%
• Each arm (including hand): 9% (4.5% for the front, 4.5% for the back)
• Each leg (including foot): 18% (9% for the front, 9% for the back)
• Anterior torso (chest and abdomen): 18%
• Posterior torso (back and buttocks): 18%
• Perineum: 1%

Since Nurse Kevin’s patient has burns on the right arm, chest, and head, we calculate the TBSA affected:

• Head: 9%
• Right arm: 9%
• Anterior chest (part of the anterior torso): 9% (since the full anterior torso is 18%)

Total TBSA burned = 9% (head) + 9% (right arm) + 9% (chest) = 27%.

 Think of the body as a pie chart divided into sections. The Rule of Nines helps estimate how much of the "pie" is burned, ensuring accurate fluid resuscitation and treatment.

Accurate TBSA estimation is critical for guiding fluid resuscitation and burn management.

• Use the Parkland formula for fluid resuscitation: 4 mL x kg x TBSA (%) of Lactated Ringer's solution, with half given in the first 8 hours and the remaining half over the next 16 hours.
• Monitor for signs of hypovolemic shock, including hypotension, tachycardia, and decreased urine output.
• Assess for airway compromise, especially in burns involving the head and chest, due to possible inhalation injury.
• Provide pain management and wound care to prevent infection and promote healing.
• Evaluate for electrolyte imbalances, as severe burns can lead to hyperkalemia and metabolic acidosis.

✘Incorrect answer options:

18%. This would be the correct answer if only two areas were affected (e.g., the head and arm or the anterior chest and arm). However, since all three areas (head, right arm, and chest) are burned, the total is 27% TBSA.

36%. This overestimates the affected TBSA. If both the anterior and posterior chest were involved along with the head and arm, the TBSA would be higher.

45%. This is too high for the burned areas described. If the patient had both arms and the entire torso (anterior + posterior) affected, then the TBSA would be closer to this value.

EXPLANATION

✔Correct answer:

The patient may experience a burning sensation when applied. Mafenide acetate (Sulfamylon) is a topical antimicrobial agent used to prevent and treat infections in burn wounds. One of its well-known side effects is a burning or stinging sensation upon application, which can be distressing to patients, especially pediatric patients. This occurs because mafenide acetate penetrates deeply into eschar and tissues, reaching areas with nerve endings that are still intact.

Despite this discomfort, mafenide acetate is highly effective in preventing Pseudomonas aeruginosa and other bacterial infections in burn wounds. Nurses should prepare patients and caregivers for this expected reaction and provide reassurance that the burning sensation typically subsides after a short time.

 Imagine applying alcohol to a fresh cut—it stings at first because it reaches nerve endings, but the sensation fades as it dries. Mafenide acetate works similarly by penetrating the burn wound, which causes initial discomfort.

Nurse Lisa should take steps to minimize discomfort and ensure proper wound care.

• Inform the patient and family that a burning or stinging sensation is normal and usually temporary.
• Assess the patient’s pain level before and after application, and administer prescribed pain medication if needed.
• Monitor for allergic reactions such as rash, itching, or difficulty breathing.
• Observe for signs of metabolic acidosis, a rare but serious side effect of mafenide acetate due to its carbonic anhydrase inhibition.
• Ensure proper dressing technique to prevent contamination and promote healing.

✘Incorrect answer options:

It will cause dark discoloration of the surrounding skin. Mafenide acetate does not typically cause dark skin discoloration. In contrast, silver sulfadiazine (Silvadene), another burn treatment, can cause temporary blue-gray discoloration of the skin.

The patient may feel a cooling sensation upon application. Unlike silver sulfadiazine, which has a soothing, cooling effect, mafenide acetate causes burning or stinging due to its deeper tissue penetration.

It has the potential to interfere with thyroid function. There is no known effect on thyroid function with mafenide acetate. However, silver-containing burn treatments can sometimes interfere with thyroid activity due to their iodine interactions.

EXPLANATION

✔Correct answer:

Implement seizure precautions. Delirium tremens (DTs) is a severe and potentially life-threatening complication of alcohol withdrawal that typically occurs 48–72 hours after the last drink in individuals with a history of heavy, prolonged alcohol use. Patients experiencing DTs are at significant risk for seizures, which can lead to injury or even death if not properly managed. Therefore, the nurse’s priority intervention is to implement seizure precautions to ensure patient safety. This includes padding the bed rails, keeping the bed in a low position, removing any potential hazards from the room, and having emergency equipment readily available. Seizures associated with DTs are often generalized tonic-clonic and can occur suddenly, making immediate prevention measures critical.

Chronic alcohol use leads to central nervous system (CNS) depression and adaptive changes in neurotransmitter systems, particularly gamma-aminobutyric acid (GABA) and glutamate. When alcohol intake is abruptly stopped, the CNS becomes hyperactive due to the sudden loss of GABAergic inhibition and increased glutamatergic excitation. This hyperexcitability manifests as agitation, hallucinations, confusion, autonomic instability, and seizures, all hallmark features of DTs.

Think of the brain during alcohol withdrawal like an overcharged electrical circuit. Without the usual "buffer" provided by alcohol, the circuit becomes overloaded, leading to unpredictable surges (seizures). Implementing seizure precautions is like installing surge protectors to prevent damage.

In addition to implementing seizure precautions, nurses caring for patients with delirium tremens should focus on stabilizing the patient and preventing complications. Key interventions include:

• Continuously monitoring vital signs and neurological status to detect early signs of deterioration.
• Administering benzodiazepines (e.g., lorazepam or diazepam) as prescribed to reduce CNS hyperactivity and prevent seizures.
• Ensuring a calm and quiet environment to minimize stimulation and agitation.
• Providing thiamine and other vitamin supplementation to address nutritional deficiencies common in chronic alcohol use.
• Collaborating with the healthcare team to manage symptoms and provide supportive care.

✘Incorrect answer options:

Gather a detailed history of the patient’s alcohol use. While obtaining a detailed history of alcohol use is important for understanding the context of the patient’s condition, it is not the priority intervention in an acute emergency situation like delirium tremens. The immediate focus must be on ensuring patient safety and preventing life-threatening complications such as seizures.

Maintain a cool, dark environment. Although creating a calm and quiet environment is helpful in reducing agitation and sensory overload, it does not address the immediate risk of seizures, which is the primary concern in delirium tremens. Seizure precautions take precedence over environmental modifications.

Administer thiamine and zinc as prescribed. Thiamine administration is essential to prevent Wernicke-Korsakoff syndrome, a serious complication of chronic alcoholism. However, while thiamine replacement is a critical component of care, it is not the priority intervention in the acute phase of delirium tremens when seizure risk is highest. Seizure precautions must come first.

EXPLANATION

✔Correct answer:

No specific preparation is required for this test.  The blood test for Helicobacter pylori (H. pylori) detects antibodies against the bacteria, indicating a current or past infection. Unlike other diagnostic tests for H. pylori, such as the urea breath test or stool antigen test, the blood test does not require fasting or special preparation. Patients can eat, drink, and take medications as usual before the test. However, it is important to note that serologic tests can detect past infections and may not confirm an active infection.

 Think of the H. pylori blood test like checking for old battle scars. It tells whether your body has fought H. pylori before but doesn’t confirm if the battle is still ongoing. Unlike other tests that check for active bacteria, this one just looks for past exposure.

Nurse Olivia should ensure the patient understands the purpose and limitations of the blood test while considering alternative testing methods for more accurate results.

• Inform the patient that a positive blood test indicates past exposure but does not confirm an active infection.
• Educate the patient about additional diagnostic tests, such as the urea breath test or stool antigen test, which may be needed to confirm an active infection.
• Reassure the patient that no fasting or medication restrictions are necessary for the blood test.
• Coordinate with the healthcare provider to determine the best diagnostic approach if H. pylori infection is suspected.
• Discuss the importance of follow-up testing, especially if treatment for H. pylori is required.

✘Incorrect answer options:

Avoid eating or drinking anything after midnight. This instruction applies to fasting blood tests, such as glucose or lipid panels, but is unnecessary for H. pylori antibody testing.

A small amount of radioactive isotope will be administered. This describes the urea breath test, not the blood test. In the urea breath test, the patient drinks a solution containing urea labeled with a carbon isotope, and exhaled carbon dioxide is analyzed to detect active H. pylori infection.

An oral glucose suspension must be taken an hour before the test. This refers to an oral glucose tolerance test (OGTT), which is used to diagnose diabetes, not H. pylori infection.

EXPLANATION

✔Correct answer:

Digestive enzymes can lead to skin breakdown. The peristomal skin, which is the skin surrounding the stoma, is particularly vulnerable in patients with an ileostomy due to the nature of the effluent (output) from the stoma. An ileostomy diverts waste from the small intestine directly to the abdominal surface, bypassing the colon. This effluent contains digestive enzymes, such as proteases and lipases, which are highly irritating to the skin. If these enzymes come into contact with the peristomal skin, they can cause irritation, erythema, maceration, or even ulceration, leading to significant discomfort and potential infection. Proper fitting of the ostomy appliance and the use of protective skin barriers are essential to prevent leakage and protect the skin from enzymatic damage.

The small intestine produces liquid stool that is rich in digestive enzymes and bile acids. Unlike colostomy output, which tends to be more formed due to water absorption in the colon, ileostomy output is typically loose and frequent. These characteristics increase the risk of peristomal skin complications if the appliance does not fit securely or if there is prolonged exposure to the effluent.

Imagine your skin as a delicate fabric, and the ileostomy effluent as a strong detergent. Just as detergent can weaken and damage fabric over time, the digestive enzymes in ileostomy output can irritate and break down the skin unless it’s properly protected.

Nurses should prioritize meticulous peristomal skin care to prevent complications and promote patient comfort. Key interventions include:

• Assessing the peristomal skin at each pouch change for signs of irritation, redness, or breakdown.
• Selecting and fitting the ostomy appliance carefully to ensure a secure seal and minimize leakage.
• Educating the patient on proper hygiene practices, including gentle cleansing with warm water and avoiding harsh soaps or alcohol-based products.
• Applying skin barrier products, such as pastes or powders, to protect the skin from enzymatic irritation.
• Encouraging regular follow-up with a wound, ostomy, and continence (WOC) nurse for ongoing support and troubleshooting.

✘Incorrect answer options:

Stools are less watery and contain more solid matter. This statement is incorrect because ileostomy output is typically liquid or semi-liquid due to the absence of water absorption by the colon. The high moisture content and presence of digestive enzymes make the effluent particularly caustic to the skin, increasing the need for careful peristomal care.

The stoma will take longer than usual to heal. While healing time may vary depending on individual factors, the primary concern with peristomal skin care is not the healing of the stoma itself but rather the prevention of skin damage caused by exposure to digestive enzymes. Stomal healing generally occurs within the first few weeks post-surgery.

It is challenging to fit the appliance to the stoma site. Although achieving a proper fit is important, this is not the primary reason for cautious peristomal skin care. The main issue lies in the chemical irritation caused by the effluent, which necessitates preventive measures regardless of how well the appliance fits.

EXPLANATION

✔Correct answer:

A glass of orange juice. Iron supplements are best absorbed in an acidic environment, and vitamin C (ascorbic acid) enhances iron absorption by converting ferric iron (Fe³⁺) into ferrous iron (Fe²⁺), which is more easily absorbed by the body. Orange juice is rich in vitamin C, making it an ideal choice for improving the absorption of oral iron supplements.

Patients with iron-deficiency anemia should also be advised to take iron on an empty stomach for maximum absorption, unless gastrointestinal side effects (e.g., nausea) require them to take it with food.

Think of iron like a rusty nail—it needs a strong solvent to break it down and make it usable. Vitamin C in orange juice acts like a powerful cleaner that helps dissolve the iron so your body can absorb it more efficiently.

Nurse Sarah should educate the patient on the best practices for iron supplement administration to optimize treatment effectiveness.

• Encourage taking iron with a source of vitamin C, such as orange juice, strawberries, or citrus fruits.
• Advise taking iron on an empty stomach, at least 1 hour before or 2 hours after meals, for better absorption.
• Inform the patient that iron may cause gastrointestinal side effects, including nausea and constipation, and suggest increasing fiber and fluid intake if needed.
• Warn against consuming calcium-rich foods (e.g., milk, cheese) or caffeine (e.g., coffee, tea) with iron, as these can inhibit absorption.
• Educate the patient that iron supplements may cause dark or black stools, which is a normal, harmless side effect.
• Encourage compliance with regular follow-up lab tests to monitor hemoglobin and ferritin levels.

✘Incorrect answer options:

Plain water only. While taking iron with water is acceptable, it does not enhance absorption like vitamin C does. Taking iron with acidic beverages (e.g., orange juice) is preferable.

A glass of milk. Milk contains calcium, which inhibits iron absorption by competing for the same absorption sites in the intestines. Dairy products should be avoided within 2 hours of taking iron supplements.

A glass of apple juice. While apple juice contains some vitamin C, it has lower levels than orange juice. Therefore, orange juice is the better option for maximizing iron absorption.

EXPLANATION

✔ Correct answer:

Morphine. In acute pancreatitis, severe abdominal pain is a hallmark symptom caused by inflammation, edema, and autodigestion of pancreatic tissue. Morphine is the preferred opioid analgesic for pain management in this condition due to its potent analgesic effects and long duration of action. It provides effective pain relief without increasing pancreatic enzyme secretion significantly.

Acute pancreatitis involves inflammation of the pancreas, leading to activation of digestive enzymes within the pancreatic tissue. This results in intense pain, often radiating to the back. Pain management is crucial to reduce sympathetic stimulation, which can worsen the inflammatory process.

Historically, meperidine was preferred due to concerns that morphine might cause sphincter of Oddi spasm, potentially worsening pancreatitis symptoms. However, research has not strongly supported this, and morphine is now recommended because it provides longer-lasting analgesia and has a better safety profile than meperidine, which can cause neurotoxicity (seizures and tremors) with prolonged use.

Imagine a fire (inflammation) in a kitchen (pancreas). Pain relief is like using a fire extinguisher. Morphine is a strong extinguisher that effectively controls the flames, while meperidine is a weaker option that may come with unwanted side effects.

Since opioid analgesics can have side effects, Nurse Riley should monitor the patient closely after administering morphine.

• Assess pain level using a pain scale before and after administration.
• Monitor for respiratory depression, especially in elderly or opioid-naïve patients.
• Observe for side effects such as nausea, vomiting, constipation, and sedation.
• Encourage deep breathing and mobility to prevent atelectasis and pulmonary complications.
• Ensure the patient is receiving adequate IV hydration, as fluids help reduce pancreatic inflammation.
• Collaborate with the healthcare team for additional interventions such as NPO (nothing by mouth) status, nasogastric suctioning, and enzyme replacement therapy if necessary.

✘ Incorrect answer options:

Meperidine: While meperidine was previously used for pancreatitis pain, it is no longer preferred due to its short half-life and risk of neurotoxicity (seizures, tremors) with repeated dosing.

Ketorolac: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that is not typically used for severe pain in acute pancreatitis. NSAIDs can also increase the risk of renal impairment in these patients, who may already have fluid imbalances.

Codeine: Codeine is a mild opioid analgesic and is not strong enough to manage the severe pain associated with acute pancreatitis. Additionally, codeine can cause gastric irritation and constipation, which may worsen the patient's condition.