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A nurse is teaching a client who has a new prescription for fluoxetine. Which of the following statements should the nurse include?
- A. "You should expect to feel an improvement in your symptoms within 1 week."
- B. "You may experience weight gain while taking this medication."
- C. "You should take this medication in the morning to prevent insomnia."
- D. "You should stop taking this medication if you experience dry mouth."
Correct Answer: B
Rationale: The correct statement the nurse should include is that the client may experience weight gain while taking fluoxetine. Weight gain is a common side effect of fluoxetine, and patients should be informed about this potential issue. Stating that the client should expect improvement in symptoms within 1 week (Choice A) is incorrect as fluoxetine may take a few weeks to have a noticeable effect. Taking the medication in the morning to prevent insomnia (Choice C) is not necessary since fluoxetine can be taken at any time of the day. Instructing the client to stop taking the medication if experiencing dry mouth (Choice D) is misleading, as dry mouth is a common but usually not serious side effect of fluoxetine.
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A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?
- A. Teaching a new mother how to breastfeed.
- B. Assisting a client with ambulation post-surgery.
- C. Helping with medication administration.
- D. Delegating IV medication administration.
Correct Answer: B
Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.
A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?
- A. Prothrombin time (PT)
- B. International Normalized Ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Fibrinogen levels
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.
A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid using aspirin for pain.
- B. I will consume dairy products to increase my calcium intake.
- C. I will drink 1.5 to 2 liters of fluid each day.
- D. I will need to limit my intake of fiber.
Correct Answer: A
Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.
A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serosanguineous drainage on the surgical dressing.
- B. Temperature of 37.8°C (100°F).
- C. Urine output of 75 mL in the past 4 hours.
- D. WBC count of 15,000/mm³.
Correct Answer: D
Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.
A client receiving warfarin is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid eating leafy green vegetables while taking this medication.
- B. I will need to have my INR checked regularly while taking this medication.
- C. I will take this medication at the same time each day.
- D. I will avoid taking aspirin while taking this medication.
Correct Answer: D
Rationale: The correct answer is D because clients taking warfarin should avoid aspirin to reduce the risk of bleeding, as both medications can thin the blood. Choice A is incorrect because it is essential to eat a consistent amount of leafy green vegetables to maintain a steady intake of Vitamin K, which can impact warfarin's effectiveness. Choice B is incorrect although important because INR checks are necessary but do not specifically show an understanding of the teaching. Choice C is incorrect because while taking warfarin at the same time each day is beneficial for consistency, it does not directly address the interaction with aspirin.