Nokea
A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?
- A. ''I am allergic to morphine.''
- B. ''I take antacids several times a day.''
- C. ''I had a blood clot in my leg several years ago.''
- D. ''It hurts to take a deep breath.''
Correct Answer: B
Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.
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When teaching a client with tuberculosis, which statement should the nurse include?
- A. You will need to continue taking the multi-medication regimen for 4 months.
- B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.
- C. You will need to remain hospitalized for treatment.
- D. You will need to wear a mask at all times.
Correct Answer: B
Rationale: Monitoring the effectiveness of tuberculosis medication is crucial to ensure the treatment is working properly. Regular sputum samples help in assessing the response to the medication. This monitoring can guide adjustments in the treatment plan if needed. Options A and C are incorrect as they do not reflect essential aspects of tuberculosis treatment. Option D is not a standard recommendation for tuberculosis treatment and may lead to misconceptions.
A healthcare provider is caring for a group of clients. Which of the following clients is not at risk for pulmonary embolism?
- A. A client who has a BMI of 30
- B. A female client who is postmenopausal
- C. A client who has a fractured femur
- D. A client who has chronic atrial fibrillation
Correct Answer: B
Rationale: Postmenopausal status is not a significant risk factor for pulmonary embolism. Risk factors for pulmonary embolism include obesity (BMI of 30 or higher), immobility such as having a fractured femur, and conditions like chronic atrial fibrillation that increase the risk of blood clot formation. While postmenopausal status may be associated with other health risks, it is not directly linked to an increased risk of pulmonary embolism.
A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
- B. ''I will lie on my back with my knees bent.''
- C. ''I will rest my hand over my abdomen to create resistance.''
- D. ''I will take in a deep breath and hold it before exhaling.''
Correct Answer: D
Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.
When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?
- A. Administer antibiotics
- B. Provide supplemental oxygen
- C. Administer antiviral medications
- D. Administer bronchodilators
Correct Answer: A
Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.
A client with active tuberculosis is prescribed isoniazid, rifampin, pyrazinamide, and ethambutol. Which statement by the client indicates an understanding of the teaching?
- A. I can substitute one medication for another if I run out because they all fight infection.
- B. I will wash my hands each time I cough.
- C. I am glad I don't have to have any more sputum specimens.
- D. I don't need to worry about where I go once I start taking my medications.
Correct Answer: B
Rationale: The correct statement indicating understanding of tuberculosis medication regimen is 'I will wash my hands each time I cough.' This statement shows knowledge of infection control practices to prevent the spread of tuberculosis. Washing hands after coughing helps in reducing the transmission of the disease to others. The other options are incorrect. Option A is incorrect as each medication in the regimen has a specific role, and substituting one for another can compromise the effectiveness of treatment. Option C is incorrect as obtaining sputum specimens is essential for monitoring treatment response. Option D is incorrect as the client should still adhere to infection control measures and avoid exposing others to tuberculosis.