Nokea
A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use ibuprofen when I have a headache.
- B. I will use an electric razor for shaving
- C. I will avoid the use of stool softeners.
- D. I will massage the site after each injection.
Correct Answer: B
Rationale: Using an electric razor reduces bleeding risk with enoxaparin, an anticoagulant. Ibuprofen increases bleeding, stool softeners may be needed, and massaging injection sites is contraindicated.
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A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
- A. Distended neck veins
- B. Polyuria
- C. Vomiting
- D. Hypertension
- E. Fever and chills
- F. Tachycardia
- G. Hypotension
Correct Answer: C
Rationale: Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.
A nurse is reinforcing teaching with a client who is newly diagnosed with dumping syndrome. Which of the following instructions should the nurse include in the teaching?
- A. Remain upright for 30 min after eating.
- B. Eat three large meals per day.
- C. Drink water with meals.
- D. Eliminate simple sugars.
Correct Answer: D
Rationale: Dumping syndrome occurs post-gastric surgery when food moves too quickly into the small intestine, causing nausea, diarrhea, and weakness. Eliminating simple sugars is key sugars draw fluid into the gut, worsening osmotic shifts and symptoms. Remaining upright helps slow gastric emptying but isn't the primary dietary fix. Eating three large meals overloads the stomach, triggering rapid dumping, whereas small, frequent meals are recommended. Drinking water with meals dilutes stomach contents, accelerating emptying and exacerbating symptoms; fluids should be taken between meals. Cutting simple sugars (e.g., candy, soda) reduces hyperosmolarity, stabilizes digestion, and aligns with evidence-based management, improving quality of life. This instruction empowers the client to control symptoms through diet, a cornerstone of dumping syndrome care, making it the most effective teaching point.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Medical History
Today, 0700:
Admitting Diagnosis: Heart Failure
Past medical history of heart failure, coronary artery disease, sleep apnea
Client reports diarrhea, dry mouth, and unusual thirst for the past three days
A nurse is assisting in the care of a male client who has a new prescription for furosemide. Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide?
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. Client verbal report
- E. BUN
Correct Answer: A
Rationale: Furosemide, a loop diuretic, treats heart failure but depletes potassium, risking hypokalemia. A low potassium level (e.g., <3.5 mEq/L) contraindicates its use hypokalemia causes arrhythmias, especially with heart failure's cardiac strain, per pharmacology standards. Blood pressure matters hypotension may worsen with diuresis but isn't a direct contraindication unless extreme. Digoxin use heightens hypokalemia risk (enhancing toxicity), but potassium level drives the decision. The client's report of diarrhea and thirst suggests dehydration, a caution, not a strict contraindication. Low potassium demands correction (e.g., supplements) before furosemide, preventing lethal complications like ventricular fibrillation, making it the critical finding to identify.
Nurses' Notes
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg Just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
Which of the following actions should the nurse take? (Post-fasciotomy)
- A. Prepare to administer an antibiotic
- B. Administer an analgesic
- C. Restrict fluid intake.
- D. Prepare to obtain a wound culture.
- E. Initiate supplemental oxygen.
- F. Elevate the leg.
- G. Monitor dressing.
Correct Answer: A,B,D
Rationale: Antibiotics prevent infection, analgesics manage pain, and a wound culture assesses for infection post-fasciotomy.
A nurse is preparing to administer medications to a female client. Which of the following medications is included in the Medication Administration Record?
- A. Furosemide 40 mg PO daily
- B. Potassium chloride 10 mEq/L PO twice daily
- C. Lisinopril 10 mg PO daily
- D. NPH insulin 26 units SUBQ daily
- E. Atorvastatin 20 mg PO daily
Correct Answer: A
Rationale: The question tests medication record accuracy, with furosemide 40 mg PO daily listed as an option. It's a diuretic for heart failure (per Exhibit 4), matching the client's diagnosis, and is correctly formatted for administration. Potassium chloride addresses diuretic-induced losses, lisinopril manages hypertension, and NPH insulin treats diabetes, all plausible, but furosemide ties directly to the heart failure noted. Its inclusion ensures fluid overload is addressed, a primary concern, aligning with MAR standards right drug, dose, route, and frequency. This choice confirms the nurse's role in verifying orders, making it the appropriate medication to recognize.