Nokea
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.
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A 6-year-old is admitted to the ED after ingesting oxycodone tablets that had been prescribed for the parent. The parent provides the prescription bottle that originally contained 15 tablets of oxycodone 5 mg. The parent stated taking 3 tablets. There are 9 tablets remaining in the bottle. If the child ingested the missing tablets, how many mg of oxycodone did the child ingest?
Correct Answer: 15
Rationale: 15 - 3 = 12; 12 - 9 = 3; 3 tablets x 5 mg = 15 mg. The child ingested 15 mg of oxycodone.
The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?
- A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinivir)
- B. two non-nucleoside reverse transcriptase inhibitors
- C. one protease inhibitor such as Nelfinavir
- D. two protease inhibitors
Correct Answer: B
Rationale: Unless there is drug resistance, the initial prophylaxis based on CDC recommendations is 2 NNRTIs.
The nurse should perform which intervention when a client is restrained?
- A. Remove the restraints and provide skin care hourly.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes.
- D. Tie the restraint to the side rails.
Correct Answer: C
Rationale: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.
Which of these comments by a client would indicate the need for further teaching regarding safety with warfarin (Coumadin)?
- A. I need to stop the medication 3 days before my dental appointment.'
- B. I will report any bruising or bleeding to my doctor.'
- C. I plan to eat more green leafy vegetables this week.'
- D. I will check with my doctor before taking any new medication.'
Correct Answer: C
Rationale: Green leafy vegetables are high in vitamin K, which can counteract the anticoagulant effects of warfarin, requiring further teaching to ensure safe dietary practices.
The nurse is caring for a client who has just returned from the operating room after a cholecystectomy. Which of these findings requires immediate follow-up by the nurse?
- A. A temperature of 100.4°F (38°C)
- B. Pulse rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Oxygen saturation of 88%
Correct Answer: D
Rationale: An oxygen saturation of 88% indicates hypoxia, requiring immediate intervention to prevent respiratory compromise.