Nokea
Although nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?
- A. Urinary incontinence
- B. Constipation
- C. Nystagmus
- D. Occult bleeding
Correct Answer: D
Rationale: Occult bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal tract.
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A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
- A. Blood urea nitrogen 50 mg/dl
- B. Hemoglobin of 10.3 mg/dl
- C. Venous blood pH 7.30
- D. Serum potassium 6 mEq/L
Correct Answer: D
Rationale: Serum potassium 6 mEq/L. Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately.
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
- A. apply suction for no more than 10 seconds
- B. maintain sterile technique
- C. lubricate 3 to 4 inches of the catheter tip
- D. withdraw catheter in a circular motion
Correct Answer: A
Rationale: Applying suction for more than 10 seconds may result in hypoxia. Although options B, C, and D are important during suctioning a tracheostomy, hypoxia results from actions that decrease the oxygen supply.
A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
- A. Chest pain
- B. Pallor
- C. Inspiratory crackles
- D. Heart murmur
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.
The nurse is wearing PPE. Place the steps to removing the PPE in the correct sequence.
- A. Remove gown
- B. Remove gloves and perform hand hygiene
- C. Remove mask
- D. Remove eye protection
- E. Perform hand hygiene
Correct Answer: B,D,A,C,E
Rationale: B: Gloves are removed first due to high contamination risk, followed by hand hygiene. D: Eye protection is removed next. A: Gown is removed before leaving. C: Mask is removed at the doorway. E: Final hand hygiene ensures cleanliness.