A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?
- A. You should avoid drinking alcohol while taking this medication.
- B. You should monitor for signs of infection.
- C. Take this medication with food to prevent gastrointestinal upset.
- D. Take this medication with a full glass of water.
Correct Answer: B
Rationale: The correct statement the nurse should include when teaching a client taking clopidogrel is to monitor for signs of infection. Clopidogrel affects platelet levels and can increase the risk of bleeding. Monitoring for signs of infection is crucial because a compromised immune system can make the client more susceptible to infections. Choices A, C, and D are incorrect because clopidogrel is not directly linked to alcohol restrictions, food requirements, or specific water intake instructions.
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A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?
- A. Heart rate 60/min.
- B. Blood pressure 110/70 mm Hg.
- C. Serum potassium 4 mEq/L.
- D. Blood pressure 120/80 mm Hg.
Correct Answer: B
Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serous drainage at the incision site
- B. Temperature 38.2°C (100.8°F)
- C. Heart rate 92/min
- D. Blood pressure 130/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.
A nurse is caring for a client who has experienced a stroke and has aphasia. Which of the following communication strategies should the nurse use?
- A. Speak louder to help the client understand
- B. Speak using simple sentences and gestures
- C. Use a picture board to facilitate communication
- D. Have the client practice writing words down
Correct Answer: C
Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.
A client in active labor has ruptured membranes. What action should the nurse take?
- A. Apply a fetal heart rate monitor.
- B. Initiate fundal massage.
- C. Administer oxytocin IV.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.
A client has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Hemoglobin
Correct Answer: A
Rationale: When a client is prescribed furosemide, monitoring potassium levels is crucial due to the drug's potential to cause hypokalemia. Furosemide is a loop diuretic that promotes potassium excretion in the urine, leading to a risk of low potassium levels. Monitoring potassium levels helps in detecting and preventing hypokalemia, which can result in adverse effects like cardiac dysrhythmias. Sodium, calcium, and hemoglobin levels are usually not directly affected by furosemide, making them less pertinent for monitoring in this specific scenario.