Nokea
A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority to reinforce for this client?
- A. Bleeding risk
- B. Bronchospasm
- C. Muscle injury
- D. Tinnitus
Correct Answer: A
Rationale: Anticoagulants/antiplatelets for CAD/AF increase bleeding risk , the highest priority. Bronchospasm , muscle injury , and tinnitus are less relevant.
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The nurse is providing care in the home to a person who has AIDS. Which behavior, if observed by the nurse, indicates a need for further instruction?
- A. The client uses the same dishes as the rest of the family.
- B. The client shares a bathroom with the rest of the family.
- C. The client and his brother use the same razor.
- D. The client often cooks for the family.
Correct Answer: C
Rationale: Sharing razors risks bloodborne HIV transmission, requiring education. Using shared dishes, bathrooms, or cooking poses no significant risk with standard precautions.
The nurse is caring for a client with anorexia nervosa. After experiencing a weight gain of 2 lb (0.9 kg), the client states, 'See what you have done to me? I am fatter and uglier than ever.' Which of the following actions would be most appropriate for the nurse to take?
- A. Acknowledge the client's distress and explore the client's underlying feelings.
- B. Remind the client that gaining weight is a criterion for discharge home.
- C. Encourage the client to write about the client's feelings in a journal
- D. Recommend the client receive cognitive behavioral therapy.
Correct Answer: A
Rationale: Acknowledging distress and exploring feelings builds trust and addresses body image issues. Discharge criteria , journaling , or therapy are less immediate.
The nurse is providing home care to a man who had a transsphenoidal hypophysectomy the day before yesterday. Which behavior by the client indicates a need for more teaching?
- A. He bends over to tie his shoes.
- B. He tells the nurse he takes a lot of pills every day.
- C. He ambulates daily.
- D. He tells the nurse he has ordered a medical identification bracelet.
Correct Answer: A
Rationale: Bending over increases intracranial pressure, risking cerebrospinal fluid leak post-hypophysectomy, indicating a need for further teaching on activity restrictions.
The nurse is reviewing new orders for a client with chronic kidney disease. The nurse should clarify the order for
- A. dietary sodium restriction
- B. magnesium hydroxide
- C. fluid restriction
- D. furosemide
Correct Answer: B
Rationale: Magnesium hydroxide risks toxicity in CKD due to impaired excretion. Sodium restriction , fluid restriction , and furosemide are appropriate.
The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?
- A. I can come back at the end of my shift when I am able to stay longer.
- B. I will ask a friend or family member to stay with you if you would like.
- C. I can stay and sit with you for a short time if you would like.
- D. I will contact the chaplain to sit with you and your spouse
Correct Answer: C
Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.