Nokea
A nurse is assessing a client who has a new prescription for enoxaparin. Which of the following findings is a priority for the nurse to report?
- A. Platelet count of 200,000/mm³
- B. Hemoglobin level of 15 g/dL
- C. Respiratory rate of 22/min
- D. Dark, tarry stools
Correct Answer: D
Rationale: The correct answer is D. Dark, tarry stools indicate gastrointestinal bleeding, which is a serious side effect of enoxaparin that requires immediate medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal ranges and are not directly related to the adverse effects of enoxaparin, so they do not take precedence over the urgent concern of gastrointestinal bleeding.
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A client who is at 30 weeks of gestation and is scheduled for a nonstress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid drinking fluids during the test.
- B. I will need to drink a sugar solution before the test.
- C. This test will monitor how my baby is responding to contractions.
- D. This test will assess for fetal lung maturity.
Correct Answer: B
Rationale: The correct answer is B because the client should drink a sugar solution for a glucose challenge test, which is part of the nonstress test protocol during pregnancy. Choice A is incorrect because adequate hydration is generally recommended before the test. Choice C is incorrect as the nonstress test monitors the baby's heart rate in response to its own movements, not contractions. Choice D is incorrect as the nonstress test does not assess fetal lung maturity.
If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct Answer: A
Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.
A nurse is planning care for a client who has tuberculosis. Which of the following actions should the nurse take to prevent the transmission of the disease?
- A. Place the client in droplet isolation.
- B. Place the client in airborne isolation.
- C. Wear a surgical mask when providing care to the client.
- D. Keep the client's door closed at all times.
Correct Answer: B
Rationale: The correct answer is B: 'Place the client in airborne isolation.' Tuberculosis is an airborne disease transmitted through droplet nuclei. Placing the client in airborne isolation helps prevent the spread of the disease to others. Choice A, placing the client in droplet isolation, is incorrect because tuberculosis is not transmitted through large droplets. Choice C, wearing a surgical mask when providing care to the client, is not sufficient as airborne precautions are necessary. Choice D, keeping the client's door closed at all times, does not directly address the prevention of disease transmission in this case.
What is the most effective intervention for a patient experiencing acute pain?
- A. Administer analgesics
- B. Reposition the patient
- C. Provide non-pharmacological interventions
- D. Administer IV fluids
Correct Answer: A
Rationale: Administering analgesics is the most effective intervention for a patient experiencing acute pain as it directly targets the pain receptors and provides relief. Repositioning the patient may help in some cases, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management but might not provide immediate relief. Administering IV fluids is not a standard intervention for acute pain unless dehydration is contributing to the pain.
A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Use a heating pad to warm your feet.
- D. Trim toenails straight across.
Correct Answer: D
Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.