Nokea
A client who has a history of mitral valve prolapse tells the nurse that she is scheduled to get her teeth cleaned. Which of the following replies by the nurse is most appropriate?
- A. The physician will need to reevaluate the status of your heart condition before your dental appointment.'
- B. The nurse to remind your dentist that you have a heart condition.'
- C. It is important for you to care for your teeth because your heart condition makes you more susceptible to developing oral infections.'
- D. We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned.'
Correct Answer: D
Rationale: Clients with mitral valve prolapse may require prophylactic antibiotics before dental procedures to prevent infective endocarditis, depending on current guidelines. This is the most appropriate response as it directly addresses the need for preventive measures. The other options either lack specificity or do not address the immediate clinical concern.
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Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:
- A. Control chest pain.
- B. Reduce coronary artery vasospasm.
- C. Control the arrhythmias associated with MI.
- D. Revascularize the blocked coronary artery.
Correct Answer: D
Rationale: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
The nurse has just admitted a 35-year-old female client who has a serum vitamin B12 concentration of 800 pg/mL. Which of the following laboratory findings should cue the nurse to focus the client history assessment on specific drug or alcohol use?
- A. Total bilirubin, 0.3 mg/dL.
- B. Serum creatinine, 0.5 mg/dL.
- C. Hemoglobin, 16 g/dL.
- D. Folate, 1.5 ng/mL.
Correct Answer: D
Rationale: A serum vitamin B12 level of 800 pg/mL is within the normal range (200–900 pg/mL), but a folate level of 1.5 ng/mL is low (normal: 2.7–17 ng/mL). Low folate levels can be associated with chronic alcohol use, as alcohol impairs folate absorption and metabolism. The nurse should assess the client's history for alcohol use, as this may contribute to the folate deficiency. The other lab values (bilirubin, creatinine, hemoglobin) are normal and do not suggest drug or alcohol use.
A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4°F (38°C). What should the nurse do first?
- A. Obtain a culture of the incision.
- B. Notify the surgeon to obtain an antibiotic order.
- C. Adjust the client to a sitting position to take deep breaths.
- D. Administer an antipyretic medication.
Correct Answer: C
Rationale: A pulse oximetry of 91 indicates mild hypoxemia. Adjusting to a sitting position and encouraging deep breaths improves oxygenation, addressing the most immediate concern.
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?
- A. I should take my antacid at the same time as my other medications.'
- B. I need to decrease my intake of fluids so that I don't dilute the effects of my antacid.'
- C. My antacid will be most effective if I take it whenever I experience stomach pains.'
- D. It is best for me to take my antacid 1 to 3 hours after meals.'
Correct Answer: D
Rationale: Antacids are most effective when taken 1 to 3 hours after meals, as they neutralize gastric acid during peak acid secretion. Taking antacids with other medications can interfere with absorption, and fluid intake does not need to be restricted.