Nokea
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication?
- A. Blood pressure of 140/84 mm Hg
- B. Heart rate of 98/min
- C. Platelet count of 200,000/mm^3 (200 x 10^9/L)
- D. Report of Ginkgo biloba use
- E. Report of peptic ulcer disease
Correct Answer: D,E
Rationale: Ginkgo biloba (D) and peptic ulcer disease (E) increase bleeding risk with clopidogrel, requiring caution. Blood pressure (A), heart rate (B), and platelet count (C) are within normal limits.
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The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?
- A. prolonged inspiration with each breath
- B. expiratory wheezes that are suddenly absent in 1 lobe
- C. expectoration of large amounts of purulent mucous
- D. appearance of the use of abdominal muscles for breathing
Correct Answer: B
Rationale: Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Sudden cessation of wheezing is an ominous sign that indicates an emergency -- the small airways are now collapsed.
An 8-year old is admitted with drooling, muffled phonation and a temperature of 102.6°. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:
- A. Strep throat
- B. Epiglottitis
- C. Laryngotracheobronchitis
- D. Bronchiolitis
Correct Answer: B
Rationale: Drooling, muffled phonation, and fever suggest epiglottitis, a medical emergency requiring immediate intervention due to the risk of airway obstruction.
A client using a diaphragm should be instructed to:
- A. Refrain from keeping the diaphragm in longer than 8 hours.
- B. Keep the diaphragm in a warm location.
- C. Have the diaphragm resized if she gains 5 pounds.
- D. Have the diaphragm resized if she has any surgery.
Correct Answer: A
Rationale: Leaving a diaphragm in place longer than 8 hours increases infection risk. Resizing is needed for significant weight changes (e.g., 10+ pounds) or post-surgery, not minor changes.
A client scheduled for electroconvulsive therapy tells the nurse, 'I'm so afraid. What will happen to me during the treatment?' Which of the following statements is most therapeutic for the nurse to make?
- A. You will be given medicine to relax you during the treatment
- B. The treatment will produce a controlled tonic clinic seizure
- C. The treatment can produce nausea and headache
- D. You can expect to be sleepy and confused for a time after the treatment
Correct Answer: A
Rationale: Explaining that medication will relax the client addresses their fear and provides reassurance about the procedure's safety, making it the most therapeutic response.
The nurse caring for a client with an ileal conduit observes that the stoma appears bluish gray. What is the nurse's best action?
- A. Administer an antibacterial agent and assess for additional signs of infection
- B. Document the findings and continue to monitor for changes
- C. Measure the stoma and obtain a larger pouching device
- D. Report the findings to the health care provider immediately
Correct Answer: D
Rationale: A bluish-gray stoma (D) indicates ischemia, requiring immediate reporting. Antibiotics (A) are premature, monitoring (B) delays care, and resizing the pouch (C) is irrelevant.