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A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?
- A. Crushing the medication would release all the medication at once, rather than over time
- B. Crushing the medication might cause you to have a stomachache or indigestion
- C. Crushing the medication is a good idea, and I can mix in some ice cream for you
- D. Crushing is unsafe, as it destroys the ingredients in the medication
Correct Answer: B
Rationale: The correct answer is B. Crushing enteric-coated aspirin can lead to stomachache or indigestion because the coating is designed to protect the stomach lining from irritation. By crushing it, the medication can be released too quickly, causing irritation. Choice A is incorrect because it focuses on the timing of medication release rather than the potential harm of crushing it. Choice C is incorrect as adding ice cream does not address the issue of medication safety. Choice D is incorrect as it does not provide a specific reason why crushing is unsafe.
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A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
- A. The client who has a nasogastric (NG) tube to suction
- B. The client who has a chest tube to water seal
- C. The client who has an indwelling urinary catheter to gravity drainage
- D. The client who has a tracheostomy tube attached to humidified oxygen
Correct Answer: A
Rationale: The correct answer is A: The client who has a nasogastric (NG) tube to suction. Suctioning through the NG tube can lead to loss of gastric contents, including potassium, which can result in hypokalemia. The other choices do not directly affect potassium levels. B: A chest tube to water seal is used to drain air or fluid from the pleural space, not likely to cause hypokalemia. C: An indwelling urinary catheter to gravity drainage does not impact potassium levels. D: A tracheostomy tube with humidified oxygen does not affect potassium levels. Therefore, the client with the NG tube to suction is at risk for hypokalemia due to potential potassium loss.
A nurse is teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?
- A. Increase in startle reflex
- B. Increase in muscle mass
- C. Decrease in body fat
- D. Decrease in systolic blood pressure
Correct Answer: A
Rationale: The correct answer is A: Increase in startle reflex. As individuals age, their neurological system undergoes changes leading to increased sensitivity and exaggerated responses, including an increase in the startle reflex. This change is attributed to alterations in neurotransmitter levels and sensory processing.
Incorrect Answers:
B: Increase in muscle mass - Muscle mass typically decreases with age due to hormonal changes and decreased physical activity.
C: Decrease in body fat - Older adults tend to experience an increase in body fat and a decrease in muscle mass, contributing to changes in body composition.
D: Decrease in systolic blood pressure - While blood pressure tends to increase with age due to changes in blood vessel elasticity and hormonal changes, a decrease in systolic blood pressure is not a common expected physiological change in older adults.
A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?
- A. Clean the skin near the drain in a circular motion from the outside to the inside
- B. Empty the drainage device when it is half full
- C. Place a perforated gauze pad around the drain to absorb drainage
- D. Connect the drain to continuous low-pressure suction
Correct Answer: C
Rationale: Rationale: Choice C is correct because placing a perforated gauze pad around the drain helps absorb drainage and prevents skin irritation. This promotes wound healing and prevents infection. Choice A is incorrect as it can introduce bacteria into the wound. Choice B is incorrect because drainage should be emptied when it reaches a certain level, not necessarily when it is half full. Choice D is incorrect as Penrose drains do not require suction.
A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?
- A. Use hot water to rinse hand sanitizer off
- B. Dry hands with a reusable towel
- C. Rub hands together 20 seconds
- D. Rub hand sanitizer around rings on fingers
Correct Answer: D
Rationale: The correct answer is D: Rub hand sanitizer around rings on fingers. This is important because rings can harbor bacteria and viruses, and by rubbing hand sanitizer around them, the nurse ensures that all surfaces of the hands, including under the rings, are effectively sanitized. This action helps prevent the transmission of pathogens.
A: Using hot water to rinse hand sanitizer off is unnecessary and can actually be harmful as it can cause skin irritation.
B: Drying hands with a reusable towel is not recommended as it can harbor germs and compromise hand hygiene.
C: Rubbing hands together for 20 seconds is a good practice, but the specific action related to rings is more crucial.
E, F, G: No information provided.
A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.8
Rationale: The correct answer is 0.8 mL. To determine this, divide the desired dose (30 mg) by the concentration (40 mg/mL) to get 0.75. Since we need to round to the nearest tenth, 0.75 rounds up to 0.8 mL. The other choices are incorrect because: A: 0.7 mL, B: 0.9 mL, C: 0.6 mL, D: 1.0 mL, E: 0.5 mL, F: 1.2 mL, G: 0.3 mL. These choices do not accurately reflect the calculated dose based on the given information.