Nokea
A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except:
- A. obtain an order for a stool softener.
- B. administer packed RBCs, if ordered.
- C. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge.
- D. dress venipuncture sites immediately to prevent infection.
Correct Answer: D
Rationale: Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality.
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Which of the following terms refers to soft-tissue injury caused by blunt force?
- A. contusion
- B. strain
- C. sprain
- D. dislocation
Correct Answer: A
Rationale: A contusion is a soft-tissue injury from blunt force, causing swelling and discoloration without breaking the skin. Strains and sprains involve ligaments or muscles, and dislocation affects joints. Physiological Adaptation
A patient with a history of myocardial infarction is prescribed aspirin. Which of the following instructions should the nurse include?
- A. Take this medication on an empty stomach.
- B. Avoid taking this medication with other NSAIDs
- C. Discontinue the medication if you experience ringing in your ears.
- D. Take this medication only when you have chest pain.
Correct Answer: B
Rationale: Avoiding other NSAIDs prevents increased bleeding risk with aspirin, a key antiplatelet post-MI. Empty stomach increases GI upset, ringing requires reporting, and aspirin is daily, not PRN.
After a painful exacerbation of rheumatoid arthritis, a patient is to begin a walking and exercise program.
An appropriate outcome would be that the patient:
- A. Avoids exercising when there is some discomfort.
- B. Is pain free while engaging in the activity program.
- C. Walks and exercise even when the pain is severe.
- D. Exercise unless the discomfort becomes too great.
Correct Answer: D
Rationale: Exercising until discomfort becomes too great balances activity with joint protection, promoting safe participation.
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.
A nurse is assigned to care for a comatose diabetic on IV insulin therapy. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Check the client's level of consciousness
- B. Obtain the regular blood glucose readings
- C. Determine if special skin care is needed
- D. Answer questions from the client's spouse about the plan of care
Correct Answer: B
Rationale: The UAP can safely obtain blood glucose readings, which are routine tasks.