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A nurse is reinforcing teaching with a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?
- A. Take this medication with food to prevent stomach upset.
- B. You might experience bruising more easily.
- C. You need to avoid eating citrus fruits.
- D. You should take this medication at bedtime.
Correct Answer: B
Rationale: Clopidogrel increases bleeding risk, leading to easy bruising. Food isn't required, citrus isn't restricted, and timing is flexible.
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A nurse is caring for a client who is postoperative following a hip replacement. Which of the following actions should the nurse take?
- A. Place an abduction pillow between the client's legs.
- B. Instruct the client to bend at the hip when sitting.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to cross their legs when seated.
Correct Answer: A
Rationale: An abduction pillow prevents dislocation by maintaining hip alignment. Bending, warm compresses, and leg crossing increase dislocation risk.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse take?
- A. Check the ventilator settings every 8 hr.
- B. Suction the endotracheal tube every 4 hr.
- C. Monitor the client's oxygen saturation continuously.
- D. Administer a bronchodilator every 12 hr.
Correct Answer: C
Rationale: Continuous oxygen saturation monitoring ensures adequate ventilation. Settings checks, suctioning, and bronchodilators depend on specific needs, not fixed schedules.
A nurse is caring for a client who is receiving IV gentamicin. Which of the following actions should the nurse take?
- A. Monitor the client's hearing.
- B. Administer the medication over 15 min.
- C. Check the client's blood glucose levels.
- D. Instruct the client to increase fluid intake.
Correct Answer: A
Rationale: Gentamicin risks ototoxicity, so hearing monitoring is critical. It's infused slowly, glucose isn't affected, and fluid intake depends on condition.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
- A. Suction the tube every 2 hr.
- B. Secure the tube to the client's face.
- C. Monitor the client's cuff pressure daily.
- D. Reposition the client every 4 hr.
Correct Answer: B
Rationale: Securing the tube prevents dislodgement, ensuring airway safety. Suctioning is as needed, cuff pressure checks are frequent, and repositioning is every 2 hours.
A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.
- A. Discarding worksheets containing client information in a wastebasket
- B. Writing a client's diagnosis on the message board in the client's room
- C. Giving change of shift report to a nurse outside the client's room
- D. Discussing a client's prognosis with an assistive personnel who is caring for the client
Correct Answer: C
Rationale: Giving a shift report in a private setting prevents unauthorized individuals from overhearing, protecting confidentiality. Discarding worksheets improperly, writing diagnoses publicly, or discussing prognosis openly risks breaches.