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A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?
- A. It dissolves blood clots
- B. It prevents the blood from clotting
- C. It thins the blood
- D. It decreases the risk of infection
Correct Answer: B
Rationale: The correct answer is B: It prevents the blood from clotting. Warfarin works as an anticoagulant by inhibiting the production of certain clotting factors in the liver. This prevents the formation of blood clots and reduces the risk of conditions like deep vein thrombosis or stroke. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones. Choice C is misleading as it does not actually "thin" the blood but affects its ability to clot. Choice D is unrelated to the mechanism of action of warfarin.
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A client with type 1 diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?
- A. Administer 15 grams of carbohydrate
- B. Administer a glucagon injection
- C. Provide a snack with protein
- D. Encourage the client to rest
Correct Answer: A
Rationale: The correct action is to administer 15 grams of carbohydrate because the client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. Carbohydrates will quickly raise the blood sugar level. Glucagon injection is used for severe hypoglycemia when the client is unconscious. Providing a snack with protein is not the immediate action needed to raise the blood sugar rapidly. Encouraging rest is not effective in treating hypoglycemia.
A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?
- A. The depth of tissue destruction is minor
- B. Pain is interrupted due to nerve compression
- C. The full thickness burn has destroyed the nerves
- D. Second-degree burns are not usually painful
Correct Answer: C
Rationale: The correct answer is C because full-thickness burns destroy nerve endings, resulting in the absence of pain sensation. The dry, waxy, and white appearance indicates tissue destruction extending through the epidermis and dermis. Choices A and D are incorrect because dry, waxy, and white appearance signifies a deeper burn, not a minor or superficial burn, and second-degree burns typically involve pain sensation. Choice B is incorrect as nerve compression does not explain the lack of pain sensation in a full-thickness burn.
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
- A. I should keep the urine specimen refrigerated.
- B. I need to start the collection in the morning after my first void.
- C. I will collect the urine for 24 hours and keep it on ice.
- D. I will start collecting the urine after discarding my first morning specimen.
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.
The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
- A. Activity tolerance as evidenced by appropriate age-level activities being performed
- B. Absence of skin breakdown as evidenced by intact skin and absence of redness
- C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
- D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr
Correct Answer: D
Rationale: The correct answer is D. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance.
A: Activity tolerance is important but not the priority in acute glomerulonephritis.
B: Absence of skin breakdown is important for overall health but not directly related to the condition.
C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis.
In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.
A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?
- A. Allow the child to eat foods desired and tolerated
- B. Restrict foods brought from fast food restaurants
- C. Recommend eating the same foods as siblings eat at home
- D. Encourage a variety of large portions of food at every meal
Correct Answer: A
Rationale: Step 1: A child with Leukemia undergoing chemotherapy often experiences anorexia, nausea, and vomiting, leading to altered nutrition.
Step 2: Allowing the child to eat foods desired and tolerated promotes intake, ensuring adequate nutrition.
Step 3: Restricting foods (Choice B) can exacerbate the child's already limited intake and lead to nutritional deficiencies.
Step 4: Recommending the same foods as siblings (Choice C) may not address the specific needs of the child undergoing chemotherapy.
Step 5: Encouraging large portions of food (Choice D) may overwhelm the child and worsen their symptoms.