Nokea
A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglobin level is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and his family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the physician and family to next:
- A. Discontinue all measures.
- B. Notify the hospital attorney.
- C. Attempt to stabilize the client through the use of fluid replacement.
- D. Give enough blood to keep the client from dying.
Correct Answer: C
Rationale: Respecting the client's religious beliefs, the nurse should focus on stabilizing the client with fluid replacement to address hypovolemia, as blood transfusions are refused.
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A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.
A client with a history of depression is prescribed escitalopram (Lexapro). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Suicidal thoughts.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Suicidal thoughts are a serious side effect of escitalopram, requiring immediate reporting to ensure client safety.
The nurse tells a rape victim that even if she was protected against pregnancy by a contraceptive and the attention of taking any legal action against her assailant, she should still be checked by a physician for early detection of which of the following?
- A. Sexually transmitted disease.
- B. Anxiety reaction.
- C. Periurethral tears.
- D. Menstrual difficulties.
Correct Answer: A
Rationale: A physician should check for sexually transmitted diseases, as rape increases the risk of infection, which requires early detection and treatment.
Clozapine (Clozaril) therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, 'Why do I have to have a blood test every week?' Which of the following responses by the nurse would be most appropriate?
- A. Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood.'
- B. Weekly blood tests are done so that you can receive another week's supply of the medication.'
- C. Your physician will want to know how well you are personally progressing with the medication therapy.'
- D. Everyone who takes this drug must go through the same procedure because it is required by the drug company.'
Correct Answer: A
Rationale: Weekly blood tests monitor for agranulocytosis, a serious side effect of clozapine, ensuring safe dosing and early detection of blood abnormalities.
The nurse is observing an unlicensed assistive personnel (UAP) care for an older client who had surgery (insertion of a prosthesis) following a hip fracture 4 days ago. To prevent client injury, the nurse should intervene in the care when which action is performed by the UAP?
- A. Elevates the head of bed 30 degrees
- B. Assists the client in inserting dentures
- C. Obtains a bedside commode to keep in the room
- D. Places pillows between the legs when turning the client
Correct Answer: C
Rationale: After hip surgery when a prosthesis has been inserted, a client should not flex the body more than 90 degrees relative to the chair; sitting on a commode would mean a low seat. The toilet seat should be raised, so a special adapted commode should be placed in the room. The head of the bed can be raised slightly for comfort. Assisting the client in inserting dentures is within the duties of a UAP. The legs should be kept abducted, so using pillows between the legs when turning is required.