Nokea
A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should:
- A. Put all four side rails up on the bed.
- B. Ask the unlicensed personnel to place restraints on the client's upper extremities.
- C. Request that the client's roommate put the call light on when the client is attempting to get out of bed.
- D. Check on the client at regular intervals to ascertain the need to use the bathroom.
Correct Answer: D
Rationale: Regular checks ensure safety and assist with bathroom needs, addressing dizziness and confusion. Side rails and restraints risk injury or agitation. Relying on a roommate is unreliable.
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When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
- A. Aching pain in the left calf
- B. Burning pain in the left calf
- C. Numbness and tingling in the left leg
- D. Coldness of the left foot and ankle
Correct Answer: D
Rationale: Complete arterial obstruction causes severe ischemia, leading to coldness of the affected limb (foot and ankle) due to absent blood flow. Aching or burning pain and numbness/tingling suggest partial occlusion or neuropathy, not complete obstruction.
A client is to receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaparin?
- A. Increase in red blood cell production.
- B. Reduction of postoperative thrombi.
- C. Decrease in postoperative bleeding.
- D. Promotion of tissue healing.
Correct Answer: B
Rationale: Enoxaparin is an anticoagulant that prevents postoperative thrombi by inhibiting clot formation, reducing the risk of deep vein thrombosis or pulmonary embolism.
The nurse is assessing a client receiving intravenous (IV) fluids via a peripheral vascular access device (PVAD). Assessment findings show swelling and tenderness at the infusion site. The nurse should perform which action?
- A. stop the infusion and remove the PVAD
- B. remove the dressing and reposition the PVAD
- C. instruct the client to perform range of motion activities in the affected arm
- D. place the arm in a dependent position
Correct Answer: A
Rationale: Swelling and tenderness indicate infiltration, requiring stopping the infusion and removing the PVAD.
The nurse is preparing to administer ten units of regular insulin and twenty units of NPH insulin. Which of the following actions is correct when mixing the insulins?
- A. Aspirate insulin from the NPH vial first.
- B. Roll the regular insulin vial prior to aspirating insulin.
- C. Aspirate the regular insulin first before NPH.
- D. Instill air into the regular insulin vial first.
Correct Answer: C
Rationale: Regular insulin is drawn up first to prevent contamination of the clear insulin with the cloudy NPH.
Which of the following signs and symptoms are common in male clients with prolactin-secreting tumors?
- A. Severe lethargy and fatigue.
- B. Erectile dysfunction and decreased libido.
- C. Both of the above
- D. None of the above
Correct Answer: B
Rationale: Prolactin-secreting tumors in males often cause erectile dysfunction and decreased libido due to suppression of testosterone.