Nokea
An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?
- A. I will walk to the room to observe the client's behavior.
- B. It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable.
- C. Just leave the client alone now and try again later.
- D. The client probably has dementia and is under a lot of stress with the change of environment.
Correct Answer: A
Rationale: Observing the client (A) allows assessment of the behavior's cause. Assuming dissatisfaction (B) or dementia (D) is premature. Leaving the client (C) delays intervention.
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A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which
- A. increase the heart rate
- B. lead to dehydration
- C. are considered aerobic
- D. may be competitive
Correct Answer: B
Rationale: lead to dehydration. The client must take in adequate fluids before and during exercise periods.
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- A. Question the order.
- B. Administer the medications.
- C. Administer them separately.
- D. Contact the pharmacy.
Correct Answer: B
Rationale: Lisinopril and furosemide are commonly prescribed together for hypertension, as lisinopril is an ACE inhibitor that reduces blood pressure, and furosemide is a diuretic that reduces fluid volume. There is no contraindication for administering them concomitantly, so answer A is incorrect. Administering them separately is unnecessary, so answer C is incorrect. Contacting the pharmacy is not needed unless there is a supply issue, so answer D is incorrect.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication?
- A. Blood pressure of 140/84 mm Hg
- B. Heart rate of 98/min
- C. Platelet count of 200,000/mm^3 (200 x 10^9/L)
- D. Report of Ginkgo biloba use
- E. Report of peptic ulcer disease
Correct Answer: D,E
Rationale: Ginkgo biloba (D) and peptic ulcer disease (E) increase bleeding risk with clopidogrel, requiring caution. Blood pressure (A), heart rate (B), and platelet count (C) are within normal limits.
A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?
- A. Contact the gynecologist for details of the operation
- B. Suspect drug seeking and suggest the client take a walk around the unit
- C. Tell the client she is probably constipated and ask for an order for Milk of Magnesia
- D. Explain to the client that her symptoms are an expected physical response to detoxification and offer comfort medications as ordered
Correct Answer: D
Rationale: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.