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During a home visit, a diabetic client begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?
- A. If you do not give yourself your insulin shots, you will die.'
- B. We can teach your daughter to give the shots so you will not have to do it.'
- C. I can arrange to have a home care nurse give you the shots every day.'
- D. What is it about giving yourself the insulin shots that bothers you?'
Correct Answer: D
Rationale: Exploring the client's concerns about insulin injections promotes understanding and helps address fears, supporting adherence to treatment.
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After surgery for bilateral adrenalectomy, the client is kept on bed rest for several days to stabilize the body's need for steroids postoperatively. Which of the following exercises will be most effective for preparing a client for ambulation after a period of bed rest?
- A. Alternately flexing and extending the knees.
- B. Alternately abducting and adducting the legs.
- C. Alternately stretching the Achilles tendons.
- D. Alternately flexing and relaxing the quadriceps femoris muscles.
Correct Answer: A
Rationale: Knee flexion and extension strengthen leg muscles, preparing the client for ambulation after bed rest.
The client's identification armband was removed to start an I.V. line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on his wrist. What is the nurse's best response?
- A. Send the removed armband with the chart and the client to the operating room.
- B. Place a new identification armband on the client's wrist before transport.
- C. Tape the cut armband back onto the client's wrist.
- D. Send the client without an armband because she can verbally identify herself.
Correct Answer: B
Rationale: Placing a new identification armband ensures accurate client identification during transport and surgery, maintaining safety and compliance with protocol.
The nurse is caring for a client receiving a continuous infusion of isotonic fluids and observes infiltration at the vascular access device. The nurse should take which action?
- A. Reduce the infusion rate and elevate the affected extremity.
- B. Stop the infusion and remove the intravenous (IV) catheter.
- C. Stop the infusion and reposition the intravenous (IV) catheter into the vein.
- D. Reduce the infusion rate and apply a warm compress to the intravenous (IV) site.
Correct Answer: B
Rationale: Infiltration requires stopping the infusion and removing the catheter to prevent further tissue damage.
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug?
- A. The drug's execution peaks in 2 hours.
- B. Maximum dosage is not achieved until 3 to 4 days after starting the medication.
- C. Effects of the drug continue for 4 to 5 days after discontinuing the medication.
- D. Protamine sulfate is the antidote for warfarin.
- E. I should have my blood levels tested periodically.
Correct Answer: B,C,E
Rationale: Warfarin's maximum effect takes 3-4 days (B), its effects persist 4-5 days after stopping (C), and periodic blood tests (e.g., INR) are required (E). Peak action is not 2 hours, and protamine sulfate is the antidote for heparin, not warfarin.
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to:
- A. Take a laxative.
- B. Follow a clear liquid diet.
- C. Administer an enema.
- D. Take an antiemetic.
Correct Answer: A
Rationale: A laxative is typically recommended after an upper GI series to help eliminate the barium used in the procedure and prevent constipation.