Nokea
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client had a hemorrhoidectomy 1 year ago.
- B. The client takes ibuprofen for headaches.
- C. The client consumed citrus juice 3 days before the test.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, can irritate the gastrointestinal tract and cause minor bleeding, potentially leading to a false-positive fecal occult blood test result.
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A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Monitor the client for weight.
- B. Check the client for increased hypopigmentation under the patch.
- C. Advise the client about increased dry mouth.
- D. Inform the client of the adverse effect of diarrhea.
Correct Answer: C
Rationale: Clonidine can cause dry mouth as a common side effect, and advising the client about this is appropriate for the plan of care.
A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. Hct
- B. INR
- C. BUN
- D. LDL
Correct Answer: B
Rationale: INR (International Normalized Ratio) is monitored for warfarin therapy to assess clotting time and ensure therapeutic anticoagulation levels.
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
- A. Trendelenburg with legs extended
- B. Supine with knees flexed
- C. Semi-Fowler's with legs extended
- D. Left-lateral with knees flexed
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.
A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure?
- A. Soreness at the incision site
- B. Serosanguineous drainage on the dressing
- C. Report of sore throat
- D. Tingling of the fingers
Correct Answer: D
Rationale: Tingling of the fingers suggests hypocalcemia due to parathyroid gland damage during thyroidectomy, a potential complication.