Nokea
A 24-year-old female client who has a history of rheumatoid arthritis (RA) is taking ibuprofen (Motrin) for pain relief. Which information should the nurse provide the client about taking this medication?
- A. Take the medication with meals
- B. Take the medication with an antacid
- C. Report any changes in stool color to your healthcare provider
- D. Avoid taking aspirin while using this medication
Correct Answer: C
Rationale: The correct answer is to instruct the client to report any changes in stool color to the healthcare provider. This is important because changes in stool color can indicate gastrointestinal bleeding, a serious side effect of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Choice A is incorrect because while taking ibuprofen with meals can help reduce stomach upset, it is not the most crucial information to provide. Choice B is incorrect as taking ibuprofen with an antacid is not a standard recommendation. Choice D is also incorrect because while ibuprofen and aspirin are both NSAIDs, they can be taken together under certain circumstances, but it's important to be cautious and follow healthcare provider recommendations.
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The nurse is planning care for a client with a stage III pressure ulcer. Which intervention is most important for the nurse to include in the plan of care?
- A. Reposition the client every 2 hours
- B. Cleanse the ulcer with normal saline
- C. Apply a moisture-retentive dressing
- D. Measure the ulcer's depth and diameter
Correct Answer: D
Rationale: The correct answer is to measure the ulcer's depth and diameter. This intervention is crucial as it helps monitor healing progress and evaluate the effectiveness of the care plan. Measuring the ulcer provides valuable information about the wound's improvement or deterioration. Repositioning the client every 2 hours (Choice A) is important for preventing further skin breakdown but may not be the priority in this case. Cleansing the ulcer with normal saline (Choice B) is essential for wound care but not the most crucial intervention at this stage. Applying a moisture-retentive dressing (Choice C) can promote healing, but assessing the ulcer's dimensions is more critical for monitoring progress.
The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?
- A. Maintain possession of the evidence collection kit at all times until submitted to law enforcement
- B. Provide discharge instructions for prophylactic antibiotics, pregnancy, and HIV prevention medication
- C. Document the characteristics of the various sites of sample collection
- D. Assist the client with toileting, hygiene, and dressing with clean clothes
Correct Answer: A
Rationale: Maintaining possession of the evidence collection kit at all times until submitted to law enforcement is crucial to ensure the integrity of the chain of custody. This step helps prevent tampering or contamination of the evidence, which is vital for the legal process. Providing discharge instructions for medications, documenting sample characteristics, and assisting the client with personal care are important aspects of care but not the immediate priority when handling forensic evidence in a sexual assault case.
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.
When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?
- A. 42
- B. 50
- C. 60
- D. 70
Correct Answer: A
Rationale: To calculate the infusion rate, we first need to determine the frequency of contractions per hour. If contractions are occurring every 2 to 3 minutes, this corresponds to 20 to 30 contractions in an hour (60 minutes). The average is 25 contractions in an hour. The pump should be infusing 1 ml for each contraction, so the infusion rate should be 25 ml/hr. Therefore, the correct answer is 42 ml/hr. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.
The mother of a 6-year-old anemic boy is taught by the nurse to give iron supplements. Which statement indicates that the mother understands the proper administration of iron?
- A. The iron tablets will be absorbed between meals, on an empty stomach
- B. I should give the iron tablets with his milk and cereal each morning
- C. Iron preparations can be taken with antibiotics if he develops an infection
- D. The iron tablets may cause him to sunburn more easily so he should wear sunscreen
Correct Answer: A
Rationale: The correct answer is A because iron supplements are best absorbed on an empty stomach, which maximizes their effectiveness. Giving iron tablets with milk or calcium-rich foods, as mentioned in choice B, should be avoided as they can decrease iron absorption. Choice C is incorrect because iron preparations should not be taken with antibiotics due to potential interactions. Choice D is also incorrect as iron tablets do not cause an increased risk of sunburn, so sunscreen is not necessary specifically due to iron supplementation.