Nokea
A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I’ll be sure to eat more foods with vitamin K.
- B. I’ll take aspirin for my headaches.
- C. I’ll use my electric razor for shaving.
- D. It’s okay to have a couple of glasses of wine with dinner each evening.
Correct Answer: C
Rationale: The correct answer is C: "I’ll use my electric razor for shaving." This statement indicates an understanding of the teaching because warfarin is a blood thinner, increasing the risk of bleeding. Using an electric razor reduces the risk of nicks and cuts, which could lead to excessive bleeding.
Incorrect choices:
A: "I’ll be sure to eat more foods with vitamin K." - Eating more vitamin K-rich foods can interfere with the effectiveness of warfarin.
B: "I’ll take aspirin for my headaches." - Aspirin is a blood thinner and should not be taken along with warfarin.
D: "It’s okay to have a couple of glasses of wine with dinner each evening." - Alcohol can interact with warfarin and increase the risk of bleeding.
Choosing option C demonstrates the client's understanding of the importance of minimizing the risk of bleeding while on warfarin therapy.
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A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?
- A. Airborne
- B. Contact
- C. Protective
- D. Droplet
Correct Answer: D
Rationale: The correct answer is D: Droplet precautions. Pertussis is primarily spread through respiratory droplets from coughing or sneezing. Droplet precautions involve wearing a mask and eye protection to prevent transmission through these droplets. Airborne precautions are for diseases spread through small particles, contact precautions are for direct physical contact, and protective precautions are not a standard type of transmission-based precaution. Droplet precautions are the most appropriate choice for pertussis to prevent the spread of the infection to others.
A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?
- A. Reduced chest width
- B. Increased force of isometric contraction
- C. Decreased muscle mass
- D. Thickened vertebral discs
Correct Answer: C
Rationale: The correct answer is C: Decreased muscle mass. As people age, there is a natural decline in muscle mass known as sarcopenia. This can lead to reduced strength and mobility. Choice A, reduced chest width, is not a typical age-related musculoskeletal change. Choice B, increased force of isometric contraction, is not a typical change and may lead to muscle fatigue. Choice D, thickened vertebral discs, is not a common age-related change and may actually lead to disc degeneration. By including decreased muscle mass in the presentation, the nurse can educate the seniors about a common musculoskeletal change that may impact their daily activities.
A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?
- A. Chicken broth
- B. Flavored gelatin
- C. Cranberry juice
- D. Skim milk
Correct Answer: D
Rationale: The correct answer is D: Skim milk. Skim milk is allowed on a full liquid diet as it is easily digested and provides essential nutrients. It is also a good source of protein and calcium, important for healing post-surgery. Chicken broth (A) and flavored gelatin (B) are typically allowed on a clear liquid diet but may not be suitable for a full liquid diet. Cranberry juice (C) is acidic and may be too harsh on the stomach post-surgery. Therefore, the nurse should advise the client to choose skim milk for his meal tray to support healing and recovery.
A nurse is preparing to administer 1 mg vitamin K to a newborn. The medication is available in 1 mg/0.5 mL. How much should the nurse administer? (Round to the nearest tenth. Use a leading zero when applicable. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: Correct Answer: 0.5 mL
Rationale: To administer 1 mg of vitamin K, the nurse should administer 0.5 mL, as the medication is available in 1 mg/0.5 mL concentration. This means that in 0.5 mL, there is 1 mg of vitamin K. Therefore, the nurse should administer 0.5 mL to provide the correct dosage to the newborn.
Summary:
- Choice A: Incorrect, as it does not match the concentration of the medication.
- Choices B-G: Irrelevant as they do not provide the correct calculation based on the medication concentration.
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
- A. Akathisia
- B. Tardive dyskinesia
- C. Dystonia
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Tardive dyskinesia is a common adverse effect of long-term antipsychotic medication use, such as chlorpromazine. It is characterized by involuntary movements of the tongue and face. This condition is often irreversible and can be distressing for the client. Akathisia (choice A) is a different extrapyramidal side effect characterized by restlessness and the urge to move constantly. Dystonia (choice C) is another extrapyramidal side effect that presents as sustained muscle contractions causing abnormal postures. In this case, the symptoms described in the question are more indicative of tardive dyskinesia due to the specific type of involuntary movements observed in the client.