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A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse?
- A. Client eats a vegetarian diet
- B. Client has chronic atrial fibrillation
- C. Client takes indomethacin for osteoarthritis
- D. Client's platelet count is 176,000/mm³ (176 × 10â¹/L)
Correct Answer: C
Rationale: Indomethacin, an NSAID, increases bleeding risk when combined with apixaban, an anticoagulant, making it concerning. The other data are not significant.
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A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
- A. Maintain fluid and electrolyte balance
- B. Control nausea
- C. Manage pain
- D. Prevent urinary tract infection
Correct Answer: C
Rationale: Manage pain. The immediate goal of therapy is to alleviate the client's pain, which can be quite severe with kidney stones.
Which of the following meals provides the lowest amount of potassium?
- A. Orange, cream of wheat, bacon
- B. Toast, jelly, soft boiled egg
- C. Raisin bran, milk, grapefruit
- D. Melon, pancakes, milk
Correct Answer: B
Rationale: Toast, jelly, and soft-boiled egg are low in potassium compared to fruits like oranges, grapefruit, or melon, which are high in potassium.
The nurse is talking with a 74-year-old client with previously well-controlled hypertension. The client currently has a blood pressure of 190/88 mm Hg and has had a cold with nasal congestion for the past 3 days. Which of the following questions would be most important for the nurse to ask?
- A. Have you received the influenza vaccine recently?
- B. Are you taking over-the-counter cold medications?
- C. Have you spent time with your grandchildren recently?
- D. Are you taking over-the-counter vitamin C supplements?
Correct Answer: B
Rationale: OTC cold medications (e.g., decongestants) can elevate blood pressure, explaining the sudden increase, making this the most important question.
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?
- A. Have you shared your concerns with your health care provider (HCP)?
- B. If I were you, I would be more worried about whether the melanoma has spread.
- C. Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications.
- D. There is special make-up you can use to hide any facial scars left from the surgery.
Correct Answer: C
Rationale: This response addresses the client's concern about appearance by providing education on wound care to minimize scarring, promoting empowerment and trust. A deflects the concern without addressing it. B dismisses the client's feelings and focuses on an unrelated issue. D assumes scarring and offers a cosmetic solution prematurely, which may not address the client's emotional needs.
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
- A. To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
- B. To cover the bony prominence and areas where there is skin breakdown
- C. The client knows what type of clothing to wear when weighed
- D. To reduce the tendency of the client to hide objects under his or her clothing
Correct Answer: D
Rationale: To reduce the tendency of the client to hide objects under his or her clothing. Clients may conceal weights to falsely indicate weight gain.