Nokea
A client with a history of chronic migraines is admitted with complaints of nausea. The nurse should give priority to:
- A. Administering antiemetics
- B. Monitoring blood pressure
- C. Administering oxygen
- D. Monitoring temperature
Correct Answer: A
Rationale: Antiemetics relieve nausea in migraines, improving comfort and preventing dehydration.
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The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
- A. I will have blood drawn every month.'
- B. I will assess my skin for a rash.'
- C. I take aspirin for a headache.'
- D. I will use an electric razor to shave.'
Correct Answer: C
Rationale: Taking aspirin while on warfarin increases bleeding risk due to their combined anticoagulant effects. The client needs further teaching to avoid aspirin. Monthly blood draws (for INR), checking for rashes (a side effect), and using an electric razor (to reduce cuts) are appropriate.
The nurse is assessing a client with suspected tuberculosis. Which precaution should be implemented?
- A. Standard precautions
- B. Airborne precautions
- C. Droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Tuberculosis is transmitted via airborne droplets, requiring airborne precautions (e.g., N95 mask, negative pressure room). Standard, droplet, and contact precautions are insufficient.
The home care nurse is preparing a teaching plan for a client with deficiencies in folic acid. Which foods will increase the clients' folic acid level?
- A. Broccoli
- B. Cabbage
- C. Chicken
- D. Dried fruit
- E. White bread
- F. Milk
Correct Answer: A, B, D
Rationale: Folic acid-rich foods include broccoli (A), cabbage (B), and dried fruit (D). Chicken (C), white bread (E), and milk (F) are low in folate.
A client with a history of breast cancer is admitted with complaints of lymphedema. The nurse should give priority to:
- A. Providing compression therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Compression therapy reduces swelling in lymphedema post-breast cancer, improving comfort and function.
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that he will be kept NPO for 24 hours before the exam
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- D. Explain that his vital signs will be checked frequently after the test
Correct Answer: D
Rationale: Post-liver biopsy, vital signs are monitored frequently to detect hemorrhage or shock, the most likely complications.