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A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?
- A. History of gastrointestinal bleeding
- B. Prothrombin time of 12 seconds
- C. Platelet count of 180,000/mm³
- D. Creatinine level of 1.0 mg/dL
Correct Answer: A
Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.
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What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?
- A. Apply a cold compress
- B. Notify the physician immediately
- C. Apply a warm compress
- D. Administer anti-inflammatory medication
Correct Answer: C
Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.
What is the most important step when preparing to administer a blood transfusion?
- A. Check if the client has a fever
- B. Ensure the blood type is compatible with the client
- C. Administer the blood via IV push
- D. Ensure the blood is warmed to body temperature
Correct Answer: B
Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.
A nurse is caring for a client who has dementia and frequently gets out of bed unsupervised. What is the best intervention to prevent falls?
- A. Place a bed exit alarm
- B. Use restraints to prevent the client from getting out of bed
- C. Ask the client's family to stay at the bedside
- D. Encourage frequent ambulation with assistance
Correct Answer: A
Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. The client ambulates with his slippers on over his antiembolic stockings
- C. The client uses a front-wheeled walker when ambulating
- D. The client had pain meds 30 minutes ago
Correct Answer: C
Rationale: The correct answer is C. After knee arthroplasty, it is essential for the client to use a front-wheeled walker when ambulating to ensure stability and prevent falls. Sharing this information with the assistive personnel (AP) is crucial for the client's safety and proper rehabilitation. Choices A, B, and D are incorrect because the roommate's independence, the client's footwear over stockings, and the timing of pain medication administration are not directly related to the safe ambulation of a client post-knee arthroplasty.
A client scheduled to begin chemotherapy is discussing alopecia with a nurse. Which of the following statements should the nurse make?
- A. Avoid washing your hair during treatment
- B. Your oncologist might prescribe a cold cap during treatment to reduce hair loss
- C. You'll need to apply sunscreen to the scalp
- D. You'll likely experience regrowth of hair within 6 months after treatment ends
Correct Answer: B
Rationale: The correct answer is B. The nurse should inform the client that their oncologist might prescribe a cold cap during treatment to reduce chemotherapy-induced hair loss by cooling the scalp. Choice A is incorrect as washing the hair during treatment is generally recommended. Choice C is incorrect as sunscreen is not typically needed for the scalp in this context. Choice D is incorrect as regrowth of hair can vary among individuals and is not guaranteed within a specific timeframe.