A nurse is preparing to administer enoxaparin 1.5 mg/kg subcutaneously to a client who weighs 175 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 119
Rationale: The client's weight is 175 lb = 79.5 kg (175 ÷ 2.2). Dose = 1.5 mg/kg × 79.5 kg = 119.25 mg, rounded to 119 mg.
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A nurse is reinforcing dietary teaching with a client who is postoperative and adheres to a vegetarian diet. Which of the following foods should the nurse recommend to the client as containing the highest amount of protein?
- A. Tomato soup
- B. Bananas
- C. Avocado
- D. Black beans
Correct Answer: D
Rationale: Black beans are a rich source of plant-based protein, making them the best recommendation for a vegetarian client needing protein post-surgery.
A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?
- A. Perform breast self-examinations during the middle of your cycle.
- B. Perform breast self-examinations while lying on your side.
- C. Use small, circular motions, working vertically up and down across the breast.
- D. Use the palm of your hand to detect the presence of any large masses under the skin.
Correct Answer: C
Rationale: Using small, circular motions in a vertical pattern is the correct technique for breast self-examination, making this an appropriate statement.
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.
A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?
- A. Empty the pouch when it is 1/3 to 1/2 full.
- B. Use a standard enema set to irrigate the colostomy.
- C. Cleanse the skin surrounding the stoma with moisturizing soap.
- D. Cut the opening in the skin barrier 1/4 inch larger than the stoma.
Correct Answer: A
Rationale: Emptying the pouch when 1/3 to 1/2 full prevents leakage and maintains skin integrity, a key aspect of ostomy care.
A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?
- A. The client has inspiratory stridor
- B. The client reports a sore throat.
- C. The client's sputum has streaks of blood.
- D. The client's temperature is 38.6°C / 101.4°F
Correct Answer: A
Rationale: Inspiratory stridor indicates possible airway obstruction or swelling post-bronchoscopy, a serious complication requiring immediate reporting.
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