Nokea
A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
- A. Increase the infusion rate.
- B. Administer protamine sulfate immediately.
- C. Stop the heparin infusion for 1 hr.
- D. Decrease the heparin dose.
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.
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A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching?
- A. Avoid dairy products.
- B. Use disposable utensils for meals.
- C. Sleep next to family members.
- D. Increase iodine-rich foods in your diet.
Correct Answer: B
Rationale: The correct answer is B: Use disposable utensils for meals. This is important to prevent contamination of utensils by the radioactive iodine, which can be harmful to others. A - Avoiding dairy products is irrelevant for radioactive iodine therapy. C - Sleeping next to family members can expose them to radiation. D - Increasing iodine-rich foods can interfere with the therapy. Thus, B is the most appropriate instruction to include in the teaching.
A nurse is providing teaching to a client about strategies to manage menopausal symptoms. Which of the following instructions should the nurse include in the teaching?
- A. Use water-based lubricant during intercourse to reduce discomfort.
- B. Take estrogen supplements without consulting a provider.
- C. Limit calcium intake to reduce bloating.
- D. Avoid all physical activity to conserve energy.
Correct Answer: A
Rationale: The correct answer is A: Use water-based lubricant during intercourse to reduce discomfort. This instruction is important for managing menopausal symptoms like vaginal dryness and discomfort during intercourse. Water-based lubricants can help alleviate these symptoms. Option B is incorrect as taking estrogen supplements without consulting a provider can have risks and side effects. Option C is incorrect because limiting calcium intake is not recommended during menopause, as calcium is important for bone health. Option D is incorrect as avoiding physical activity can worsen menopausal symptoms and impact overall health.
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the clients coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?
- A. Notify risk management.
- B. Inform the transferring agency of the clients condition.
- C. Contact the family regarding the clients condition.
- D. Privately interview the client about the injuries.
Correct Answer: D
Rationale: Correct Answer: D - Privately interview the client about the injuries.
Rationale:
1. As a healthcare provider, the nurse must prioritize the well-being and safety of the client.
2. Privately interviewing the client allows for a confidential conversation to gather information directly from the client.
3. This approach respects the client's autonomy and confidentiality.
4. It enables the nurse to assess the situation, gather more details, and determine if further actions are needed to address the suspected elder abuse.
5. Notifying risk management (A) is important but should come after gathering information from the client.
6. Informing the transferring agency (B) may not address the immediate concern of potential abuse.
7. Contacting the family (C) may not be appropriate if they are involved in the abuse.
8. Failing to interview the client may result in a missed opportunity to address the issue effectively.
Summary:
Option D is correct as it prioritizes the client's well-being, respects autonomy, and
A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat a high-protein diet before exercise.
- B. I will check my blood sugar level before exercising.
- C. I will avoid all forms of sugar.
- D. I will only take my insulin when I feel symptoms of high blood sugar.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Checking blood sugar before exercise is crucial for individuals with type 1 diabetes to prevent hypoglycemia.
2. It allows the client to adjust their insulin dosage or carbohydrate intake based on their blood sugar level.
3. Monitoring blood sugar helps maintain safe levels during physical activity.
4. Other choices are incorrect as high-protein diet may not be necessary, avoiding all sugar is extreme, and insulin should be taken as prescribed, not based on symptoms.
A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will place my used tissues in a plastic bag.
- B. I will share my utensils with my family.
- C. I will not need to wear a mask at home.
- D. I will stop taking my medications when I feel better.
Correct Answer: A
Rationale: The correct answer is A: "I will place my used tissues in a plastic bag." This statement indicates understanding of infection control for tuberculosis by properly disposing of contaminated materials to prevent the spread of the disease. Placing used tissues in a plastic bag helps contain the bacteria.
Choices B, C, and D are incorrect:
B: Sharing utensils can spread the infection to family members.
C: Not wearing a mask at home can expose others to the bacteria.
D: Stopping medications prematurely can lead to treatment failure and drug resistance.