Nokea
A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?
- A. Avoid Alka-Seltzer because it contains aspirin
- B. Take Alka-Seltzer at a different time of day than the warfarin
- C. Select an antacid that does not interact with warfarin
- D. Use one-half the recommended dose of Alka-Seltzer
Correct Answer: A
Rationale: Avoid Alka-Seltzer because it contains aspirin. Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.
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You were about to give AM care, a patient requested for pain medication after returning from surgery 24 hours ago.
What do you do first?
- A. Take VS, assess pain, do AM care.
- B. Give medication, take VS, assess pain, do AM care.
- C. Take VS, give medication, do AM care.
- D. Perform AM care, give medication, assess pain.
Correct Answer: C
Rationale: Vital signs must be assessed before administering pain medication to ensure the patient is stable and to establish a baseline.
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client's:
- A. Level of consciousness
- B. Gag reflex
- C. Urinary output
- D. Movement of extremities
Correct Answer: B
Rationale: Assessing the gag reflex is critical post-esophagoscopy to ensure the client can swallow safely, as local anesthesia may impair this reflex.
A client with mastoiditis has a left mastoidectomy with tympanoplasty. The nurse should observe the client for signs of damage to the sixth crania nerve, which include:
- A. Inability to chew
- B. Inability to look laterally
- C. Inability to swallow
- D. Loss of scalp sensation
Correct Answer: B
Rationale: The sixth cranial nerve (abducens) controls lateral eye movement, so damage would result in an inability to look laterally.
Which of the following lab reports indicates that a client with acute glomerulonephritis is improving?
- A. Positive ASO titer
- B. Increased C reactive protein
- C. Negative eosinophil count
- D. Decreased erythrocyte sedimentation rate
Correct Answer: D
Rationale: A decreased erythrocyte sedimentation rate indicates reduced inflammation, suggesting improvement in acute glomerulonephritis.
For which of the following conditions might blood be drawn for uric acid level?
- A. asthma
- B. gout
- C. diverticulitis
- D. meningitis
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels, which are measured to confirm diagnosis and monitor treatment. The other conditions do not typically involve uric acid testing. Reduction of Risk Potential