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A nurse is reinforcing teaching with a client who is scheduled for a bone marrow biopsy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to fast for 12 hours before the procedure.
- B. I will receive general anesthesia during the procedure.
- C. I will lie on my side during the procedure.
- D. I will need to avoid walking for 24 hours after the procedure.
Correct Answer: C
Rationale: Lying on the side facilitates access to the iliac crest, a common site for bone marrow biopsy.
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A nurse is reinforcing teaching with a client who has a new prescription for warfarin. Which of the following over-the-counter medications should the nurse identify as safe for use with warfarin?
- A. Docusate
- B. Ibuprofen
- C. Aspirin
- D. Omeprazole
Correct Answer: A
Rationale: Docusate is correct. Docusate is a stool softener, and it does not have a significant effect on blood clotting. Therefore, it is considered safe for use with warfarin, which requires careful monitoring to avoid interactions that may increase bleeding risks.
A nurse is caring for a client who has a new prescription for trazodone. Which of the following adverse effects should the nurse monitor for?
- A. Drowsiness
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Trazodone, an antidepressant, commonly causes drowsiness, which can affect safety and coordination.
A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?
- A. Assist with a referral to a home health care agency.
- B. Call the provider about admitting the client to the facility overnight.
- C. Give the client a list of home care assistants to contact.
- D. Contact the next of kin to assist the client at home.
Correct Answer: A
Rationale: Assist with a referral to a home health care agency is correct. If the client has no one to assist them at home after surgery, a home health care agency can provide the necessary support. This is a proactive solution to ensure the client has assistance for postoperative recovery, including monitoring for complications, assistance with mobility, and other care needs.
A nurse is caring for a client who has a new prescription for duloxetine. Which of the following adverse effects should the nurse monitor for?
- A. Insomnia
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Duloxetine, an SNRI, can cause insomnia due to its effect on serotonin and norepinephrine levels.
A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?
- A. Encourage the toddler to flush the toilet while still seated.
- B. Have the toddler remain on the toilet for a minimum of 20 min.
- C. Wake the toddler every 2 hr. in the night to prevent bed-wetting.
- D. Give the toddler a sticker after each successful toileting attempt.
Correct Answer: D
Rationale: Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.