Nokea
A client is to be discharged on warfarin (Coumadin®) therapy, and the nurse is teaching the client about the medication. Which of the following statements by the client indicates that the client's education has been effective? Select all that apply.
- A. I should use a soft toothbrush.
- B. My stools will routinely be black.
- C. Swimming is a good choice for exercise.
- D. I should wear a Medical Alert bracelet.
- E. I should avoid all green, leafy vegetables.
Correct Answer: A,C,D
Rationale: Soft toothbrush (A), swimming (C), and Medical Alert bracelet (D) reduce bleeding risk and ensure safety. Black stools (B) indicate bleeding, and avoiding all leafy greens (E) is excessive.
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The ED nurse is caring for a client whose native tongue is not English. The client speaks Korean and only understands a few words of English. The nurse understands that which response is best regarding how to communicate with this client?
- A. ask a bilingual family member to tell the client to point to where the pain is
- B. call the oncology unit and ask for the nurse who is a native Korean to come and translate
- C. show the client the equipment before using it, such as indicating that an IV line will be placed in the arm
- D. call for an official Korean interpreter on the facility's translator hotline to communicate with the client, family, and health care provider
Correct Answer: D
Rationale: Using an official interpreter ensures accurate, unbiased communication, adhering to ethical and legal standards for patient care.
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:
- A. Place the client in Trendelenburg position
- B. Increase the infusion of normal saline
- C. Administer atropine intravenously
- D. Move the emergency cart to the bedside
Correct Answer: B
Rationale: Hypotension and unresponsiveness suggest hypovolemia or shock, so increasing the normal saline infusion is the initial action to restore volume.
The nurse is assessing a client with suspected Addison’s disease. Which of the following findings would the nurse expect?
- A. Weight gain and edema.
- B. Hyperpigmentation of the skin.
- C. Hypertension and tachycardia.
- D. Increased appetite and polyuria.
Correct Answer: B
Rationale: hyperpigmentation of the skin is a classic sign of Addison’s disease due to increased ACTH production
A client is admitted for an CAT scan. The nurse should question the client regarding:
- A. Pregnancy
- B. A titanium hip replacement
- C. Allergies to antibiotics
- D. Inability to move his feet
Correct Answer: A
Rationale: Pregnancy is a contraindication for a CAT scan due to radiation risks to the fetus.
The physician has prescribed Cyclogel (cyclopentolate hydrochloride) drops for a client following a scleral buckling. The nurse knows that the purpose of the medication is to:
- A. Rest the muscles of accommodation
- B. Prevent post-operative infection
- C. Constrict the pupils
- D. Reduce the production of aqueous humor
Correct Answer: A
Rationale: Cyclopentolate is a cycloplegic that paralyzes the ciliary muscle, resting the muscles of accommodation.