Nokea
The client is being discharged and has been prescribed furosemide (Lasix). Which statement by the client indicates an understanding of the medication?
- A. I will take this medication on an empty stomach for optimal absorption.
- B. I will weigh myself daily and report any significant weight loss.
- C. I will include potassium-rich foods in my diet while taking this medication.
- D. I will take this medication in the morning to prevent nocturia.
Correct Answer: B
Rationale: The correct answer is B. Weighing daily and reporting significant weight loss is crucial when taking furosemide to monitor for potential fluid and electrolyte imbalances. Choice A is incorrect because furosemide is typically taken on an empty stomach for optimal absorption. Choice C is incorrect as furosemide can lead to potassium loss, so potassium-rich foods should be consumed. Choice D is incorrect because furosemide is usually taken earlier in the day to prevent nocturia, not at bedtime.
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A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?
- A. Bag bath
- B. Sponge bath
- C. Partial bed bath
- D. Complete bed bath
Correct Answer: C
Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.
The healthcare provider is caring for a client with a history of deep vein thrombosis (DVT). Which symptom would be most concerning?
- A. Pain in the affected leg
- B. Redness and warmth in the affected leg
- C. Shortness of breath
- D. Swelling in the affected leg
Correct Answer: C
Rationale: Shortness of breath is the most concerning symptom in a client with a history of deep vein thrombosis (DVT) because it could indicate a pulmonary embolism. A pulmonary embolism is a serious complication of DVT where a blood clot travels to the lungs and can be life-threatening. Immediate medical attention is required to prevent further complications. Pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT itself but do not pose the same level of immediate danger as the potential for a pulmonary embolism.
A caregiver of an immobile client requiring assistance with repositioning is being taught by a nurse on preventing back strain. Which statement by the caregiver indicates an understanding of the teaching?
- A. I will place the bed in the lowest position
- B. I will tighten my abdominal muscles prior to moving
- C. I will keep my legs straight to provide more power in the lift
- D. I will twist at the waist while pulling the draw sheet
Correct Answer: B
Rationale: The correct answer is B. Tightening the abdominal muscles before moving helps protect the back by providing core support. Keeping the legs straight (choice C) is incorrect as bending the legs is recommended to provide a stable base and prevent strain on the back. Twisting at the waist (choice D) while moving can cause back injury due to the strain on the spine. Placing the bed in the lowest position (choice A) is not directly related to preventing back strain during client repositioning, although it may be necessary for other reasons.
A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
- D. Before changing assignments, determine which staff members have fitted particulate filter masks
Correct Answer: D
Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.
The nurse is providing education about the importance of proper foot care to a patient diagnosed with diabetes mellitus. Which primary goal is the nurse trying to achieve?
- A. Prevention of plantar warts
- B. Prevention of foot fungus
- C. Prevention of neuropathy
- D. Prevention of amputation
Correct Answer: D
Rationale: The correct answer is D: Prevention of amputation. Patients with diabetes are at a higher risk of foot complications, such as ulcers, infections, and ultimately, amputations. Proper foot care education aims to prevent these serious complications. Choices A, B, and C are incorrect because while they are also important aspects of foot care, the primary goal in diabetes management is to prevent severe outcomes like amputation.