Nokea
A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?
- A. "Get up and change positions slowly."
- B. "Avoid eating aged cheese and smoked meat."
- C. "Report any unusual bruising or bleeding to the doctor immediately."
- D. "Eat the same amount of foods that contain vitamin K every day."
Correct Answer: A
Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.
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A client is being taught how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
- A. The client's belief that his needs will be met through education
- B. The nurse's empathy regarding the client's self-injection
- C. The client seeking family approval by agreeing to a teaching plan
- D. The nurse explaining the need for education to the client
Correct Answer: A
Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation to learn. When individuals perceive that their educational efforts will directly benefit them, they are more motivated to engage in the learning process. Empathy from the nurse, seeking family approval, or the nurse explaining the need for education may not be as directly tied to the client's personal benefit and may not necessarily increase motivation to learn.
A nurse is caring for a competent adult client who tells the nurse, 'I am leaving the hospital this morning whether the doctor discharges me or not.' The nurse believes that this is not in the client's best interest and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The nurse is about to commit false imprisonment by unlawfully restricting the client's freedom of movement. In this scenario, the nurse's actions of preparing to administer sedative medication against the client's will in an effort to prevent them from leaving the hospital constitute false imprisonment. Assault (choice A) involves the threat of bodily harm, which is not present here. Negligence (choice C) refers to a breach in the duty of care, which is not the primary issue in this situation. Breach of confidentiality (choice D) involves disclosing confidential information without consent, which is unrelated to the scenario described.
A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45-degree angle.
- B. Administer the medication with the needle at a 90-degree angle.
- C. Administer the medication with the needle at a 30-degree angle.
- D. Administer the medication with the needle at a 15-degree angle.
Correct Answer: B
Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.
When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?
- A. In the morning upon rising.
- B. Immediately after the client eats breakfast.
- C. Before the client goes to bed.
- D. After the client has had a drink of water.
Correct Answer: A
Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.
Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?
- A. Knee picture
- B. Ankle picture
- C. Elbow picture
- D. Wrist picture
Correct Answer: A
Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.