Nokea
A client has deep vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Administer thrombolytics as prescribed.
- B. Massage the affected extremity every 2 hours.
- C. Apply warm compresses to the affected extremity.
- D. Place the client in a supine position with the legs elevated.
Correct Answer: C
Rationale: The correct action for a nurse caring for a client with deep vein thrombosis (DVT) is to apply warm compresses to the affected extremity. Warm compresses help reduce swelling and pain in clients with DVT. Administering thrombolytics (Choice A) is not typically done without specific orders due to the risk of bleeding. Massaging the affected extremity (Choice B) can dislodge blood clots and lead to complications. Placing the client in a supine position with the legs elevated (Choice D) may increase the risk of clot dislodgment.
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When providing teaching for a child prescribed ferrous sulfate, which of the following instructions should the nurse include?
- A. Take with meals
- B. Take at bedtime
- C. Take with a glass of milk
- D. Take with a glass of orange juice
Correct Answer: D
Rationale: The correct answer is D, 'Take with a glass of orange juice.' Ferrous sulfate is best absorbed with vitamin C, making orange juice the preferred choice. Choices A, B, and C are incorrect because taking ferrous sulfate with meals, at bedtime, or with milk can reduce its absorption due to interactions with food components like calcium, inhibiting the iron absorption process.
How should a healthcare provider handle a patient with non-compliance to hypertension medication?
- A. Provide education about medication
- B. Refer the patient to a specialist
- C. Explore alternative treatments
- D. Reassess the patient in 6 months
Correct Answer: A
Rationale: Providing education about the importance of medication adherence is crucial in managing hypertension. By educating the patient about the significance of taking their medication as prescribed, the healthcare provider can help improve compliance and control the patient's blood pressure. Referring the patient to a specialist (Choice B) may be necessary in some cases but addressing non-compliance should start with education. Exploring alternative treatments (Choice C) could be considered if the current medication is not suitable, but initial steps should focus on improving adherence. Reassessing the patient in 6 months (Choice D) may be too delayed if non-compliance is an issue that needs immediate attention.
What is the primary purpose of administering insulin to a patient with diabetes?
- A. Regulate blood glucose levels
- B. Increase metabolism
- C. Prevent complications
- D. Promote insulin sensitivity
Correct Answer: A
Rationale: The correct answer is A: 'Regulate blood glucose levels.' Administering insulin to a patient with diabetes helps regulate blood glucose levels by facilitating the uptake of glucose into cells, thereby lowering high blood sugar levels. This process aims to prevent hyperglycemia and its associated complications. Choice B, 'Increase metabolism,' is incorrect as the primary role of insulin is not to increase metabolism directly. Choice C, 'Prevent complications,' is partially correct as regulating blood glucose through insulin administration does help prevent complications associated with uncontrolled diabetes, but it is not the primary purpose. Choice D, 'Promote insulin sensitivity,' is incorrect as insulin itself is administered to compensate for the lack of endogenous insulin in diabetic patients, rather than to promote sensitivity to it.
A nurse is caring for a client who is receiving radiation therapy. Which of the following findings should the nurse expect?
- A. Weight gain
- B. Mouth sores
- C. Hyperpigmentation
- D. Increased saliva production
Correct Answer: B
Rationale: The correct answer is B: Mouth sores. Mouth sores are a common side effect of radiation therapy, especially when the treatment is focused on the head or neck area. Weight gain is not typically associated with radiation therapy; instead, clients may experience weight loss due to side effects like nausea and loss of appetite. Hyperpigmentation is not a common finding related to radiation therapy. Increased saliva production is not a typical side effect of radiation therapy; instead, clients may experience dry mouth.
How should a healthcare provider care for a patient who is refusing medication?
- A. Assess the reasons for refusal
- B. Explore alternative treatment options
- C. Document the refusal
- D. Discontinue the medication
Correct Answer: A
Rationale: When a patient refuses medication, it is essential for the healthcare provider to assess the reasons for refusal. This allows the provider to understand the patient's concerns, provide education or clarification if needed, and work collaboratively with the patient to find a solution. Exploring alternative treatment options may be necessary after understanding the reasons behind the refusal. Documenting the refusal is important for legal and continuity of care purposes, but it is not the initial action to take. Discontinuing the medication without understanding the patient's reasons for refusal can lead to potential harm and is not a recommended approach.