Nokea
A client asks the home care nurse to look at the bruises on her arms and legs. The woman also tells the nurse that her gums bleed when she uses dental floss or brushes her teeth. The client is taking all of the following medications. Which is most likely related to the client's symptoms?
- A. Metformin (Glucophage)
- B. Estrogen (Premarin)
- C. Atenolol (Tenormin)
- D. Ibuprofen (Motrin)
Correct Answer: D
Rationale: Ibuprofen, an NSAID, can inhibit platelet function, causing bruising and bleeding gums. Other medications are less likely to cause these symptoms.
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A client hospitalized with bipolar disorder, manic phase, begins to talk loudly, pace the floor, and shout commands to others in the day room as he quickly changes the TV channels. The nurse's first action should include:
- A. Checking the client's medication order
- B. Escorting the client from the day room
- C. Placing the client in seclusion
- D. Finding out whether the client's behavior is upsetting others in the day room
Correct Answer: B
Rationale: Escorting the client from the day room de-escalates the situation by removing them from a stimulating environment, reducing agitation.
The nurse is teaching unlicensed personnel about preventing the spread of disease in the health care environment. The nurse knows that the personnel understand when they state that which is the most important way to prevent the spread of disease?
- A. Isolating infected clients
- B. Consistently washing hands
- C. Wearing a gown when there is a question of a client with a questionable disease
- D. Wearing gloves whenever giving care
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent disease transmission, breaking the chain of infection in healthcare settings.
The nurse is caring for a client with a history of seizures.
- A. What is the priority action for the nurse during a client’s tonic-clonic seizure?
- B. Restrain the client’s limbs to prevent injury.
- C. Place a padded tongue blade in the client’s mouth.
- D. Turn the client to the side to maintain airway.
- E. Administer lorazepam (Ativan) immediately.
Correct Answer: C
Rationale: Turning the client to the side during a seizure maintains an open airway, preventing aspiration and ensuring oxygenation, which is the priority. Restraining limbs risks injury, tongue blades are contraindicated, and medication administration follows airway management.
Lithium carbonate is prescribed for an adult. The nurse knows the client is most likely to have which condition?
- A. Depression
- B. Mania
- C. Schizophrenia
- D. Paranoia
Correct Answer: B
Rationale: Lithium carbonate is primarily used to stabilize mood in bipolar disorder, particularly for mania.
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist client to turn, deep breathe and cough
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.