Nokea
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Rationale: Acetaminophen is the appropriate pain relief option to be taken concurrently with enoxaparin because it does not interfere with platelet aggregation or clotting factors, unlike other options. Ibuprofen, naproxen sodium, and aspirin are nonsteroidal anti-inflammatory drugs (NSAIDs) which can increase the risk of bleeding when taken with enoxaparin. Acetaminophen, on the other hand, does not have the same effect on platelet function, making it a safer choice for pain relief in patients taking enoxaparin.
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Which of the following manifestations should the nurse expect?
- A. Shortness of breath
- B. Dizziness
- C. Epistaxis
- D. Headache
Correct Answer: B
Rationale: Dizziness reflects reduced circulating volume.
Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate.
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.
Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope. Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate. Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The correct answer is B: Palms of the hands. In dark-skinned individuals, cyanosis may not be as apparent in typical areas like lips or nail beds. Palms of the hands are a reliable location to assess for cyanosis as they have less melanin and blood vessels close to the surface, making cyanosis more visible. The other choices (A: Sacrum, C: Shoulders, D: Area of trauma) are not ideal locations to assess for cyanosis as they are less likely to show accurate signs due to differences in skin thickness, blood vessel distribution, and melanin content.
Which of the following actions should the nurse take?
- A. Administer a bronchodilator after the procedure
- B. Perform the procedure prior to meals.
- C. Perform the procedure twice each day.
- D. Hold hand flat to perform percussions on the child
Correct Answer: B
Rationale: Postural drainage should be done before meals to prevent nausea and vomiting.
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.