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A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?
- A. Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely
- B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
- C. Let me contact your surgeon and find out if Heparin IV therapy can be administered to you at home
- D. Why are you so anxious to leave the hospital when you know you are not well enough yet?
Correct Answer: A
Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.
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In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?
- A. Pink lips and tongue with cyanotic hands and feet
- B. Respiration rate of 40 and heart rate of 144
- C. Centralized cyanosis and tachycardia when crying
- D. Desquamation from areas of cracked, parchment-like skin
Correct Answer: C
Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.
A nurse is assessing the learning needs of a client who is diagnosed with Addison's disease. Which statement indicates that the client needs further teaching?
- A. I should take my medications daily to replace necessary hormones
- B. I need to eat a diet high in protein and carbohydrates
- C. I should avoid drinking fluids with caffeine
- D. I should notify my healthcare provider if I start feeling dizzy
Correct Answer: B
Rationale: The correct answer is B. A diet high in protein and carbohydrates is not specifically required for Addison's disease. The focus should be on maintaining a balanced diet that is rich in fruits, vegetables, whole grains, and adequate protein sources. Choice A is correct as adherence to medication therapy is crucial in managing Addison's disease. Choice C is correct as caffeine can exacerbate symptoms of Addison's disease. Choice D is correct as dizziness can be a sign of adrenal crisis in Addison's disease, and prompt notification of healthcare providers is essential.
Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for the treatment of herpes zoster (shingles)?
- A. Initiate cardiac telemetry monitoring
- B. Maintain continuous pulse oximetry
- C. Perform capillary glucose measurements
- D. Monitor serum creatinine levels
Correct Answer: D
Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.
The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, 'What do you think you're doing?' How should the nurse respond?
- A. I cannot give you this medication until you calm down.
- B. This shot will help relieve the pain in your feet.
- C. Would you prefer to learn to administer your own shot?
- D. You will feel calmer and less jittery after this shot.
Correct Answer: B
Rationale: Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication. Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses. Choice A focuses on the client's behavior rather than the therapeutic effect of the injection. Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation. Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.
A 7-year-old with cystic fibrosis (CF) has received instructions about home care. Which statement made by the child's mother indicates that further teaching is needed?
- A. My child should not have a cough at all times
- B. He needs to take pancreatic enzymes with meals and snacks
- C. He needs to use a bronchodilator every day
- D. His dietary intake needs to be high in protein and calories
Correct Answer: A
Rationale: The correct answer is A. A cough at all times is not normal in a child with cystic fibrosis (CF) and indicates the need for further teaching on CF management. Choices B, C, and D are correct statements in managing CF: taking pancreatic enzymes with meals and snacks, using a bronchodilator daily, and maintaining a high-protein and high-calorie dietary intake are all appropriate for a child with CF.