Nokea
A client is very dependent on the staff but is able to make simple decisions. The client asks, 'Would you do my laundry? I don't know how the machine works.' Which of the following responses would be best?
- A. Sure, I have time; I can do it for you.'
- B. You'll have to wait; I don't have time now.'
- C. Can your family do it for you?'
- D. Get your laundry; I'll show you how the machine works.'
Correct Answer: D
Rationale: Teaching the client to use the machine promotes independence while addressing their request.
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Which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
- A. Partial thromboplastin time
- B. Potassium level
- C. Lee-White clotting time
- D. Fibrin split product
Correct Answer: A
Rationale: Partial thromboplastin time (PTT) is essential before administering alteplase to assess bleeding risk, as it is a thrombolytic. Potassium levels and other tests are less relevant in this context.
A client with a history of type 2 diabetes is prescribed pioglitazone (Actos). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Pioglitazone can cause weight gain due to fluid retention.
Select the complication of intravenous therapy that is accurately paired with one of its interventions.
- A. Infection: Lowering the limb to promote circulation
- B. Infiltration: The application of cold to the site
- C. Extravasation: The aspiration of contents including blood from the IV cannula
- D. Hematoma: The administration of dexrazoxane
Correct Answer: C
Rationale: Aspirating contents from the IV cannula is an intervention for extravasation to remove vesicant drugs and minimize tissue damage.
A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse:
- A. When desired because sterilization is immediate.
- B. As soon as scrotal edema and tenderness resolve.
- C. When the sperm count reflects sterilization.
- D. After 6 to 10 ejaculations.
Correct Answer: C
Rationale: A vasectomy requires confirmation of azoospermia (no sperm in semen) via sperm count before unprotected intercourse to ensure sterilization, as sperm may remain in the reproductive tract initially.
The nurse is assessing a client with suspected dehydration. Which of the following findings would support this diagnosis? Select all that apply.
- A. Sunken fontanelles in an infant.
- B. Tachycardia.
- C. Increased urine specific gravity.
- D. Dry skin.
- E. Hypotension.
Correct Answer: A, B, C, D, E
Rationale: Dehydration presents with sunken fontanelles, tachycardia, increased urine specific gravity, dry skin, and hypotension due to fluid loss.