Nokea
A client who is about to be discharged from the acute care facility is receiving warfarin (Coumadin). The nurse should plan to teach the client which of the following?
- A. Take the medication on a full stomach.
- B. Do not take any over-the-counter medications without checking with your physician.
- C. Take aspirin if you need an analgesic.
- D. Avoid prolonged exposure to the sun while taking warfarin.
Correct Answer: B
Rationale: Warfarin interacts with many over-the-counter medications, risking bleeding or reduced efficacy, so physician consultation is essential. Full stomach, aspirin, or sun exposure are not primary concerns.
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The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Upper abdominal pain.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious sitagliptin side effect. Options A, C, and D are less urgent.
The LPN/LVN is to perform a sterile procedure. Which action will maintain a sterile field?
- A. Keeping the sterile field within the line of vision
- B. Opening sterile packages with sterile gloves
- C. Talking to others over the sterile field
- D. Handing the physician medicine over the sterile field
Correct Answer: A
Rationale: Keeping the sterile field in view ensures no contamination occurs, maintaining sterility during the procedure.
A client has returned to the floor from thyroidectomy surgery.
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
- A. Monitor vital signs every four hours.
- B. Observe for frequent swallowing.
- C. Monitor for signs of respiratory distress every hour.
- D. Position the client in the supine position.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated
At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. The nurse should
- A. advise the client to decrease intake of fatty foods.
- B. schedule the client for a follow-up clinic visit in one month.
- C. inform the client that the cholesterol level is within normal limits.
- D. report the finding to the physician immediately.
Correct Answer: A
Rationale: A cholesterol level of 200 mg/dL is borderline high; reducing fatty foods is appropriate. Options B, C, and D are less immediate or incorrect.
The nurse is caring for a client with a history of peptic ulcer disease who is receiving ranitidine (Zantac) 150 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Mild epigastric discomfort.
- B. Occasional heartburn.
- C. Black, tarry stools.
- D. Nausea after meals.
Correct Answer: C
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious complication in peptic ulcer disease. Options A, B, and D are less urgent.