a client is taking phenelzine nardil and their spouse would like to bring lunch from home which of the following is most appropriate for the client t a client is taking phenelzine nardil and their spouse would like to bring lunch from home which of the following is most appropriate for the client t
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1. A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?

Correct answer: grapefruit

Rationale: The correct answer is grapefruit. Clients taking MAO Inhibitors like phenelzine (Nardil) should avoid foods rich in tyramine to prevent hypertensive crisis. Grapefruit is a suitable choice as it is not high in tyramine. Bananas, avocados, and salami are foods that should be avoided due to their tyramine content, which can interact adversely with MAO Inhibitors. Therefore, choosing grapefruit is the safest option for the client.

2. A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client’s chest?

Correct answer: Fifth left interspace at the midclavicular line

Rationale: The correct placement for auscultating the apical heart rate in the area of the mitral valve is the fifth left interspace at the midclavicular line. Placing the stethoscope in the second left interspace would be to listen to the pulmonic valve, the second right interspace is for the aortic valve, and the left lower sternal border is for the tricuspid valve.

3. Which of the following indicates a hazard for a client on oxygen therapy?

Correct answer: The client is wearing a synthetic gown.

Rationale: The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.

4. The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?

Correct answer: Ask the new nurse to take care of the transfer since the client’s medical record has all of the information, and a report should not be needed.

Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.

5. Which of the following lab values is associated with a decreased risk of cardiovascular disease?

Correct answer: high HDL cholesterol

Rationale: High HDL cholesterol is associated with a decreased risk of cardiovascular disease because HDL cholesterol is known as 'good' cholesterol. It helps remove other forms of cholesterol, like LDL cholesterol, from the bloodstream, reducing the risk of plaque buildup in the arteries. Low HDL cholesterol (Choice B) is actually a risk factor for cardiovascular disease because it means there is less of the 'good' cholesterol to perform its protective functions. Low total cholesterol (Choice C) and low triglycerides (Choice D) are not necessarily associated with a decreased risk of cardiovascular disease, as the balance and types of cholesterol play a more crucial role in heart health.

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