Nokea
During your system specific assessment of your client's peripheral pulses, you note that the client's posterior tibia pulse is weak and thready. You would document this finding as:
- A. The client's posterior tibia pulse is Grade B
- B. The client's posterior tibia pulse is Grade C
- C. The client's posterior tibia pulse is 1
- D. The client's posterior tibia pulse is 2
Correct Answer: C
Rationale: A weak and thready pulse is documented as 1+ on a 0-4+ scale, indicating diminished pulse strength.
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A client with a hip fracture is scheduled for surgery. Which preoperative teaching should the nurse include?
- A. Avoid coughing post-surgery
- B. Expect to ambulate immediately
- C. Use of incentive spirometry
- D. Limit fluid intake
Correct Answer: C
Rationale: Incentive spirometry prevents postoperative pulmonary complications like atelectasis, critical for a client with limited mobility post-hip surgery.
A client with a history of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hyperglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Clozapine can cause agranulocytosis, requiring regular white blood cell monitoring.
A client with a history of gout is prescribed colchicine. The nurse should instruct the client to take the medication:
- A. Daily to prevent gout attacks.
- B. At the onset of a gout attack.
- C. With meals to enhance absorption.
- D. At bedtime to reduce side effects.
Correct Answer: B
Rationale: Colchicine is most effective when taken at the onset of a gout attack to reduce inflammation and pain.
Which of the following is an effective security plan that you may most likely want to consider for implementation within your facility?
- A. Training all nurses to serve as a part of a security response team
- B. Training all clerical staff to be a part of a security response team
- C. The restriction of visitors in a special care area
- D. Bar coded client identification bands to insure proper identification
Correct Answer: C,D
Rationale: Restricting visitors in special care areas and using bar-coded client identification bands are effective security measures to enhance safety and protect client identity, respectively.
A client with a history of bipolar disorder is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following side effects?
- A. Weight loss.
- B. Agranulocytosis.
- C. Hyperglycemia.
- D. Dry skin.
Correct Answer: B
Rationale: Carbamazepine can cause agranulocytosis, requiring regular monitoring of white blood cell counts.