Nokea
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, leading to occult blood in the stool. Monitoring stool for occult blood helps in detecting any gastrointestinal bleeding early. Serum calcium (A) is not typically affected by long-term ibuprofen use. Fasting blood glucose (C) is not directly related to ibuprofen use. Urine for white blood cells (D) is not relevant in this scenario.
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A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 38.3°C (100.9°F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A because a capillary refill of 6 seconds in the left toe indicates poor circulation, which could lead to ischemia or necrosis in the extremity. Immediate intervention is necessary to prevent further complications.
Choice B is not as urgent as it involves monitoring and managing drainage, which can be addressed after the circulation concern is addressed.
Choice C, an elevated temperature, may indicate infection but is not as immediately life-threatening as poor circulation.
Choice D, pain at the operative site, is important but does not require immediate intervention as it can be managed with pain medication.
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
- A. Make sure the client's room has positive pressure airflow.
- B. Make sure dietary plates and utensils are disposable.
- C. Wear an N95 respirator when providing direct client care.
- D. Monitor the client's temperature once every 6 hr.
Correct Answer: A
Rationale: Correct Answer: A: Make sure the client's room has positive pressure airflow.
Rationale:
1. Positive pressure airflow prevents contaminated air from entering the room, reducing the risk of infections.
2. It helps maintain a clean environment by keeping airborne pathogens out.
3. Protects the client who has a compromised immune system post-transplant.
Summary of Incorrect Choices:
B: Disposable utensils are important but do not directly protect the client from airborne infections.
C: N95 respirators are for the healthcare provider's protection, not the client's.
D: Monitoring temperature is essential but does not directly prevent infections in a protective isolation setting.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk to you before you leave.
- B. I can contact the occupational therapist to schedule a home visit.
- C. Contact your pharmacy to inquire about a different medication.
- D. You should ask your provider to prescribe a cheaper medication.
Correct Answer: A
Rationale: The correct answer is A because the nurse should address the client's financial concerns by offering a social worker to assist with resources. This option demonstrates holistic care and supports the client's well-being beyond the medical aspect. Option B is irrelevant as it does not address the medication affordability issue. Option C puts the burden on the client to find a solution. Option D is not appropriate as the client may not feel comfortable asking for a cheaper medication directly.
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.
- B. I can put the tablet against my cheek and gum.
- C. I should chew the tablet before I swallow it.
- D. I should take this medication as soon as the pain begins.
Correct Answer: D
Rationale: The correct answer is D: "I should take this medication as soon as the pain begins." This is correct because nitroglycerin is a rapid-acting medication used to relieve chest pain associated with angina. Taking it at the onset of chest pain helps dilate blood vessels and improve blood flow to the heart muscle.
Choice A is incorrect because taking another dose after 2 minutes could lead to overdose and hypotension. Choice B is incorrect as the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because nitroglycerin should not be chewed but allowed to dissolve under the tongue.