Nokea
A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply.
- A. Begin Warfarin (Coumadin).
- B. Check the postoperative CBC, INR, PTT, & platelet levels.
- C. Confirm availability of blood products.
- D. Monitor the mediastinal chest tube drainage.
- E. Start a Dopamine (Intropin) drip for a systolic BP <100.
Correct Answer: B,C,D
Rationale: Checking lab values (B), confirming blood products (C), and monitoring chest tube drainage (D) address bleeding and ensure timely intervention. Warfarin and dopamine are inappropriate for acute bleeding.
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A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide (Orinase). When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions?
- A. Potentiating the action of insulin.
- B. Lowering the renal threshold of glucose.
- C. Stimulating insulin release from functioning beta cells in the pancreas.
- D. Combining with glucose to render it inert.
Correct Answer: C
Rationale: Tolbutamide, a sulfonylurea, stimulates insulin release from pancreatic beta cells, helping to lower blood glucose levels in type 2 diabetes.
The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect?
- A. Lack of infection.
- B. Reduction in itching.
- C. Relief of muscle spasms.
- D. Decrease in nervousness.
Correct Answer: C
Rationale: Methocarbamol is a muscle relaxant, effective when muscle spasms are relieved.
Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which of the following systems?
- A. Gastrointestinal.
- B. Renal.
- C. Pulmonary.
- D. Cardiac.
Correct Answer: A
Rationale: NSAIDs commonly cause gastrointestinal side effects, such as bleeding or ulcers, so specific assessment of the GI system is critical.
Which of the following interventions would be the most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery?
- A. Encourage the client to ambulate every 2 to 4 hours.
- B. Offer 3 to 4 oz of a carbonated beverage periodically.
- C. Encourage use of a stool softener.
- D. Continue I.V. fluid therapy.
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, reducing the risk of paralytic ileus post-renal surgery by promoting gastrointestinal function.
Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
- A. A 60-year-old man with a hiatal hernia.
- B. A 36-year-old woman with three children.
- C. A 50-year-old woman caring for a spouse with cancer.
- D. A 60-year-old woman with osteoarthritis.
Correct Answer: C
Rationale: The 50-year-old caring for an immunocompromised spouse is the highest priority for influenza vaccination to prevent transmission. Others have lower risk profiles.