Nokea
Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.
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Which of the following actions should the nurse expect from the leader during the session?
- A. The leader allows the group to discuss whatever they would like to regarding their medications
- B. The leader encourages group members to remain silent until questions are called for
- C. The leader has group members vote on what they would like to learn about during the session.
- D. The leader lectures about medication adverse effects to the group members.
Correct Answer: A
Rationale: The correct answer is A. The leader should allow the group to discuss whatever they would like regarding their medications to encourage active participation and engagement. This approach promotes a patient-centered discussion, empowers group members to share their experiences, concerns, and questions, and fosters a supportive and collaborative learning environment. This helps to address individual needs and promote a deeper understanding of medication management.
Choice B is incorrect because it inhibits open communication and stifles group participation. Choice C is incorrect as it may not address the specific needs of the group and may limit the discussion to only popular topics. Choice D is incorrect as it is a passive approach and does not promote active engagement or address individual concerns.
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the cient's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
- A. Fibrinogen level
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: C
Rationale: The correct answer is C: INR. The International Normalized Ratio (INR) is used to monitor and adjust the dosage of warfarin, an anticoagulant medication. A nurse needs to report the INR level to the provider to determine if the current dosage of warfarin is effective in preventing blood clots. A higher INR indicates a longer time it takes for blood to clot, meaning the warfarin dosage might need adjustment.
Incorrect choices:
A: Fibrinogen level - Fibrinogen is a protein involved in blood clotting but is not specific for monitoring warfarin therapy.
B: aPTT - Activated Partial Thromboplastin Time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count - Platelet count measures the number of platelets in the blood and is not directly related to warfarin therapy.
Overall, the INR is the most
For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is essential in assessing neurological function and detecting abnormalities such as hyperreflexia or hyporeflexia. A normal response of 2+ indicates intact neurological pathways. Abnormal reflexes could be indicative of various neurological conditions. Pulse rate, urine output, and proteinuria are important parameters to monitor but are not specifically related to therapeutic effects. Monitoring deep tendon reflexes is crucial for detecting early signs of neurological complications and guiding appropriate interventions.
Which of the following positions should the nurse take to place the client at ease?
- A. Sit in a chair next to the bed
- B. Stand at the side of the bed.
- C. Sit on the bed next to the client.
- D. Stand at the foot of the bed
Correct Answer: A
Rationale: The correct answer is A: Sit in a chair next to the bed. This position allows the nurse to be at eye level with the client, promoting a sense of equality and rapport. Sitting also conveys a sense of attentiveness and availability for conversation. Standing at the side of the bed (B) may create a sense of distance. Sitting on the bed next to the client (C) may invade personal space. Standing at the foot of the bed (D) can be perceived as intimidating.
Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.