Nokea
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps?
- A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
- B. Check the medication administration record to verify the client's allergies.
- C. Slowly inject the medication into the site without aspirating.
- D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
- E. Ensure an air bubble is present in the prefilled enoxaparin syringe.
Correct Answer: B,E,A,D,C
Rationale: The sequence is: Verify allergies (B), check the air bubble (E), locate the site (A), pinch and inject at 90° (D), and inject slowly without aspirating (C) per enoxaparin protocol.
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A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take?
- A. Insert a tampon following the procedure.
- B. Reinforce teaching that the procedure involves dilation of the cervix.
- C. Place the client in the Sims' position.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: D
Rationale: A colposcopy is a diagnostic procedure to examine the cervix, vagina, and vulva after an abnormal Pap test, typically involving a speculum and mild discomfort but no cervical dilation. Option A is incorrect because inserting a tampon post-procedure could introduce infection or interfere with healing, especially if biopsies were taken. Option B is wrong as colposcopy does not require cervical dilation; it's a visual inspection, unlike procedures like a D&C. Option C, Sims' position (lateral with knees bent), is not standard lithotomy position is used instead for pelvic access. Option D is correct because advising the client to avoid sexual intercourse until healing prevents irritation, infection, or disruption of any biopsy sites, aligning with post-procedure care guidelines. This instruction supports recovery and ensures accurate follow-up results, making it the most appropriate nursing action.
A nurse is collecting data from a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Activity tolerance
- B. Weight
- C. Chest x-ray results
- D. Echocardiogram results
Correct Answer: B
Rationale: Heart failure management hinges on detecting decompensation, where weight gain from fluid retention is a red flag. Sudden increases (e.g., 2-3 lbs overnight) signal worsening congestion, necessitating prompt provider action like diuretic adjustment. Activity tolerance reflects functional status but is subjective and less urgent unless acutely dropping. Chest x-ray results show pulmonary edema or cardiomegaly, but weight offers earlier, actionable data. Echocardiogram results assess heart function long-term, not immediate changes. Daily weight monitoring is a cornerstone of heart failure care fluid overload precedes symptoms like dyspnea, making it the priority to report. This aligns with clinical guidelines (e.g., ACC/AHA), enabling timely intervention to prevent hospitalization or acute failure, emphasizing its critical role in ongoing assessment.
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. WBC count 9,000/mm³ (5,000 to 10,000/mm³)
- B. Temperature 37.3° C (99.1° F)
- C. Changed mental status
- D. Diminished reflexes
Correct Answer: C
Rationale: Older adults with bladder infections (UTIs) often lack classic symptoms, presenting with altered mental status confusion or lethargy from systemic inflammation or bacteremia, per geriatric care standards. Normal WBC (9,000/mm³) doesn't rule out UTI; leukocytosis isn't always present early. A slight fever (37.3°C) supports infection but isn't definitive alone. Diminished reflexes tie to aging or neurology, not UTI. Mental status change is a red flag prompting urinalysis and antibiotics preventing sepsis, making it the strongest indicator in this population.
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
Nurses Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following instructions should the nurse include? (Client with iron deficiency anemia)
- A. Take an antacid within 30 min after medication
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C
- D. Take the medication on an empty stomach.
- E. Increase intake of milk and dairy products.
- F. Expect immediate energy improvement.
- G. Avoid green leafy vegetables.
Correct Answer: B,C,D
Rationale: Fiber prevents constipation, vitamin C enhances absorption, and empty stomach improves uptake; antacids and dairy reduce absorption.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10⁶ µL (4.2 to 5.4 x 10⁶ µL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm³ (5,000 to 10,000/mm³)
Platelet count 180,000/mm³ (150,000 to 400,000/mm³)
Vitamin B₁₂ 159 pg/mL (160 to 950 pg/mL)
1030:
Stool for fecal occult blood negative
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following instructions should the nurse include?
- A. Take an antacid within 30 min after medication administration.
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C.
- D. Increase intake of milk and dairy products.
- E. Take the medication on an empty stomach.
Correct Answer: C
Rationale: Iron deficiency anemia treatment hinges on maximizing iron absorption. Taking the medication with vitamin C enhances uptake ascorbic acid converts ferric to ferrous iron, boosting bioavailability in the acidic stomach environment, a cornerstone of anemia management. Antacids raise gastric pH, binding iron and reducing absorption, counterproductive to correcting deficiency. Increasing fiber mitigates constipation, a side effect of iron, but isn't the primary administration focus. Milk and dairy, high in calcium, inhibit iron absorption by competing for uptake sites, worsening anemia if paired with supplements. Vitamin C's synergistic effect backed by dietary guidelines optimizes therapy, especially critical with low ferritin (8 ng/mL, Exhibit 1), empowering the client to improve hemoglobin efficiently while minimizing common pitfalls, making it the essential instruction.