Nokea
The client is prescribed amiodarone for an arrhythmia. Which side effect should the nurse teach the client to report?
- A. Mild nausea
- B. Blue-gray skin discoloration
- C. Increased appetite
- D. Dry mouth
Correct Answer: B
Rationale: Blue-gray skin discoloration is a serious side effect of amiodarone, indicating potential toxicity.
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Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with arterial occlusive disease?
- A. Clopidogrel.
- B. Streptokinase.
- C. Protamine sulfate.
- D. Enoxaparin.
Correct Answer: A
Rationale: Clopidogrel (A), an antiplatelet, is used in arterial occlusive disease to prevent thrombosis. Streptokinase (B) is a thrombolytic, protamine (C) reverses heparin, and enoxaparin (D) is for DVT.
The client is four (4) hours postoperative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client to ambulate.
- B. Assess the client's bilateral pedal pulses.
- C. Maintain a continuous IV heparin drip.
- D. Provide a clear liquid diet to the client.
Correct Answer: B
Rationale: Assessing pedal pulses (B) monitors graft patency post-AAA repair, critical at 4 hours. Ambulation (A) is premature, heparin (C) is not routine, and diet (D) awaits bowel function.
The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse?
- A. The client refuses to turn from the back to the side.
- B. The client’s urinary output is 90 mL in six (6) hours.
- C. The client wants to sit on the side of the bed.
- D. The client’s vital signs are T 98, P 90, R 18, and BP 130/70.
Correct Answer: B
Rationale: Urine output of 90 mL in 6 hours (B) (<30 mL/hr) suggests renal compromise, requiring immediate intervention. Refusing to turn (A), sitting (C), and normal vitals (D) are less urgent.
Which teaching point should the nurse include for a client with peripheral artery disease? Select all that apply.
- A. Inspect feet daily for sores or injuries.
- B. Wear tight shoes to support the feet.
- C. Stop smoking to improve blood flow.
- D. Exercise until pain occurs, then rest.
- E. Apply lotion to dry skin on legs.
- F. Avoid crossing legs when sitting.
Correct Answer: A,C,D,E,F
Rationale: Inspecting feet, stopping smoking, exercising with rest, applying lotion, and avoiding leg crossing promote circulation and prevent complications in peripheral artery disease.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my successful,' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.