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A nurse is caring for a patient who is postoperative following a mastectomy. Which of the following actions should the nurse take to promote comfort? Which action promotes comfort post-mastectomy?
- A. Elevate the affected arm.
- B. Apply a heating pad to the surgical site.
- C. Encourage deep breathing exercises.
- D. Administer NSAIDs around the clock.
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected arm. Elevating the affected arm post-mastectomy helps reduce swelling and promote lymphatic drainage, which can alleviate discomfort and promote healing. Elevating the arm also helps improve circulation and prevent complications such as lymphedema.
Choice B: Applying a heating pad to the surgical site is not recommended post-mastectomy as it can increase the risk of burns and skin irritation.
Choice C: While deep breathing exercises are beneficial postoperatively to prevent complications such as pneumonia, it does not directly promote comfort in the context of a mastectomy.
Choice D: Administering NSAIDs around the clock may help manage pain post-mastectomy, but it does not specifically address comfort or promote physical comfort promotion strategies.
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A nurse is caring for a patient who has a new prescription for metformin. Which of the following laboratory tests should the nurse monitor? Which lab test should the nurse monitor for metformin?
- A. Liver function tests
- B. Thyroid function tests
- C. Complete blood count
- D. Renal function tests
Correct Answer: D
Rationale: The correct answer is D: Renal function tests. Metformin is primarily excreted by the kidneys, so monitoring renal function tests like serum creatinine and estimated glomerular filtration rate (eGFR) is crucial to assess kidney function and prevent potential metformin-induced lactic acidosis. Monitoring liver function tests (A) is not essential for metformin therapy, as metformin is not metabolized by the liver. Thyroid function tests (B) are not directly affected by metformin. Complete blood count (C) is not typically monitored specifically for metformin therapy. Therefore, the most appropriate choice is D as it directly reflects metformin's clearance and potential for toxicity.
A nurse is caring for an older adult patient with left-sided heart failure. What assessment findings should the nurse expect? What finding should the nurse expect in left-sided heart failure?
- A. Frothy sputum
- B. Dependent edema
- C. Nocturnal polyuria
- D. Jugular distention
Correct Answer: A
Rationale: The correct answer is A: Frothy sputum. In left-sided heart failure, the failing left ventricle results in blood backing up into the lungs causing pulmonary congestion. This leads to the production of frothy, pink-tinged sputum due to blood-tinged fluid leaking into the alveoli. Dependent edema (choice B) is more indicative of right-sided heart failure. Nocturnal polyuria (choice C) is not a typical finding in left-sided heart failure. Jugular distention (choice D) is more commonly seen in right-sided heart failure due to increased venous pressure.
The nurse is preparing a medication for a patient and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take? What should the nurse do with expired medication?
- A. Discard the medication.
- B. Return the medication to the pharmacy.
- C. Notify the provider.
- D. Give the medication.
Correct Answer: B
Rationale: The correct answer is B: Return the medication to the pharmacy. Expired medication may be less effective or even harmful. By returning it to the pharmacy, the nurse ensures proper disposal, preventing potential harm to patients. Discarding the medication (choice A) is correct, but returning it to the pharmacy is preferred for proper disposal. Notifying the provider (choice C) may be done after returning the medication. Giving the medication (choice D) should never be an option due to safety concerns.
A nurse is instructing a patient who has just been prescribed bumetanide. What should the nurse include in the instructions? What should the nurse include in bumetanide instructions?
- A. Take the prescribed second dose at nighttime.
- B. Limit your fluid intake to no more than 1.5 L a day.
- C. Report any changes in hearing.
- D. Avoid foods high in potassium.
Correct Answer: C
Rationale: The correct answer is C: Report any changes in hearing. Bumetanide is a loop diuretic that can cause ototoxicity, leading to changes in hearing. Instructing the patient to report any changes in hearing is crucial to monitor for potential adverse effects. Choice A is incorrect as bumetanide is usually taken once daily in the morning to prevent nocturia. Choice B is incorrect as the patient may need to increase fluid intake to prevent dehydration. Choice D is incorrect as bumetanide can lead to hypokalemia, so foods high in potassium may be beneficial.
A nurse assumes various roles while working with patients. Which of the following describes the nursing role of protecting the patient and supporting the patient's decisions? Which role involves protecting and supporting patient decisions?
- A. Advocate
- B. Manager
- C. Caregiver
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Advocate. Nurses act as advocates by protecting the patient's rights, ensuring their voice is heard, and supporting their decisions. Advocacy involves standing up for the patient's best interests and promoting autonomy. The other choices are incorrect because: B: Manager focuses on organizing and coordinating care, C: Caregiver involves providing direct physical and emotional care, and D: Educator focuses on providing information and teaching. Advocacy uniquely encompasses protecting and supporting the patient's decisions, making it the most appropriate choice in this scenario.