Nokea
A client with a history of stroke is prescribed clopidogrel (Plavix). The nurse should monitor the client for which of the following adverse effects?
- A. Bleeding.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring.
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A client with chronic kidney disease is on a fluid restriction. How should the nurse calculate the client's daily fluid intake?
- A. Based on urine output plus 500 mL
- B. 1,000 mL regardless of weight
- C. 20 mL/kg of body weight
- D. Unlimited unless edema is present
Correct Answer: A
Rationale: Fluid intake in chronic kidney disease is typically calculated as urine output plus 500 mL to replace insensible losses while preventing fluid overload.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
- A. Hypovolemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
- A. Cover the neonate's eyes.
- B. Apply lotion to the skin.
- C. Keep the neonate swaddled.
- D. Monitor urine output daily.
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.
While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal delivery, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the physician because these findings indicate which of the following?
- A. Biliary atresia.
- B. Rh isoimmunization.
- C. ABO incompatibility.
- D. Esophageal varices.
Correct Answer: A
Rationale: Pale stools and jaundice in a neonate suggest biliary atresia, a condition requiring urgent evaluation.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?
- A. 1-2 L/min via nasal cannula.
- B. 4-6 L/min via face mask.
- C. 8-10 L/min via non-rebreather mask.
- D. 12-15 L/min via Venturi mask.
Correct Answer: A
Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.