A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?
- A. Ginkgo biloba
- B. Flaxseed powder
- C. Probiotics
- D. Echinacea
Correct Answer: A
Rationale: Ginkgo biloba can increase the risk of bleeding when taken with enoxaparin, an anticoagulant, and should be reported to the provider.
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A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
- A. Obtain the client's peak expiratory flow volume.
- B. Encourage the client to cough.
- C. Place the client in a semi-Fowler's position.
- D. Encourage the client to use a straw to sip cool liquids.
Correct Answer: C
Rationale: Placing the client in a semi-Fowler's position promotes airway clearance and comfort post-tonsillectomy, especially with an SpO2 of 93%.
A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep-vein thrombosis?
- A. Muscle spasms
- B. Absent pedal pulse
- C. Numbness of the affected extremity
- D. Warmth of the affected extremity
Correct Answer: D
Rationale: Warmth is a classic sign of deep-vein thrombosis due to inflammation and blood flow changes in the affected area.
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. Changed mental status
- B. Temperature 37.3°C (99.1°F)
- C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
- D. Diminished reflexes
Correct Answer: A
Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often presenting as confusion rather than typical urinary symptoms.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced.
A nurse is assisting in the care of a client who The first action the nurse should take is to followed by. is postoperative following an open reduction internal fixation of the right tibia. Complete the following sentence by using the lists of options. The first action the nurse should take is to..... followed by.....
- A. Assess neurovascular status.
- B. Elevate the leg.
- C. Administer prescribed pain medication
- D. Monitor vital signs
- E. Apply a sterile dressing to the wound
- F. Notify the provider
Correct Answer: A,F
Rationale: Assessing neurovascular status first identifies complications like compartment syndrome, followed by notifying the provider for urgent intervention.
A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?
- A. The client should wear a mask during transport.
- B. The nurse should wear a mask during transport.
- C. The nurse should wear a gown during transport.
- D. The client should wear a gown during transport.
Correct Answer: A
Rationale: The client wearing a mask during transport prevents the spread of droplet pathogens, consistent with droplet precautions for pneumonia.
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