Nokea
A client with a history of myocardial infarction is prescribed aspirin. The nurse should explain that the primary purpose of this medication is to:
- A. Reduce chest pain.
- B. Prevent platelet aggregation.
- C. Lower blood pressure.
- D. Decrease heart rate.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of further clot formation in clients with a history of myocardial infarction.
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The nurse is caring for a client with a history of gastric ulcer who is prescribed sucralfate (Carafate). The nurse should instruct the client to take the medication:
- A. With meals to enhance absorption.
- B. On an empty stomach.
- C. At bedtime only.
- D. With an antacid.
Correct Answer: B
Rationale: Sucralfate should be taken on an empty stomach to coat the gastric mucosa effectively, promoting ulcer healing.
You are a hospice nurse who, as part of your role, does follow up counseling and care for the significant others of deceased spouses for one year after their loss. Whose theory of grief and loss would you most likely integrate into your practice as you perform this role?
- A. Engel's theory
- B. Kubler Ross' theory
- C. Lewin's theory
- D. Warden's theory
Correct Answer: B
Rationale: Kubler-Ross' theory of the five stages of grief (denial, anger, bargaining, depression, acceptance) is widely used in hospice care to guide counseling for grieving significant others.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed dofetilide (Tikosyn). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Torsades de pointes.
- D. Weight gain.
Correct Answer: C
Rationale: Dofetilide can cause torsades de pointes, a life-threatening arrhythmia, requiring close monitoring.
The nurse is observing an unlicensed assistive personnel (UAP) care for an older client who had surgery (insertion of a prosthesis) following a hip fracture 4 days ago. To prevent client injury, the nurse should intervene in the care when which action is performed by the UAP?
- A. Elevates the head of bed 30 degrees
- B. Assists the client in inserting dentures
- C. Obtains a bedside commode to keep in the room
- D. Places pillows between the legs when turning the client
Correct Answer: C
Rationale: After hip surgery when a prosthesis has been inserted, a client should not flex the body more than 90 degrees relative to the chair; sitting on a commode would mean a low seat. The toilet seat should be raised, so a special adapted commode should be placed in the room. The head of the bed can be raised slightly for comfort. Assisting the client in inserting dentures is within the duties of a UAP. The legs should be kept abducted, so using pillows between the legs when turning is required.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow immediately halts the administration of the allergen, which is the priority in anaphylaxis.