Nokea
The client who is admitted with thrombophlebitis has an order for heparin. The medication should be administered using a/an:
- A. Buretrol
- B. Infusion controller
- C. Intravenous filter
- D. Three-way stop-cock
Correct Answer: B
Rationale: An infusion controller ensures precise heparin delivery, critical for maintaining therapeutic levels and preventing complications.
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The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
- A. Measure the urinary output
- B. Check the vital signs
- C. Encourage increased fluid intake
- D. Weigh the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalance, so checking vital signs is the priority to assess stability.
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat
- B. Place a small heater near the child's bed
- C. Turn the child at least every 2 hours
- D. Allow one side to dry before changing positions
Correct Answer: C
Rationale: Turning the child every 2 hours ensures even drying of the cast and prevents pressure sores, promoting comfort and healing.
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.
The nurse reviews a 21-year-old female's bloodwork from the lab. Which result would be charted as an abnormal finding?
- A. platelets 129
- B. RBC 4.2
- C. WBC 15.6
- D. hematocrit 38%
Correct Answer: C
Rationale: WBC 15.6 (normal 4.5-11.0 x 10³/μL) is elevated, indicating possible infection or inflammation. Platelets (150-450 x 10³/μL) are slightly low, RBC (4.2-5.4 million/μL) and hematocrit (36-46%) are normal for females.
The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?
- A. Encourage the client to express her feelings about the surgery.
- B. Insist that the client look at the surgical site.
- C. Perform the wound care without involving the client.
- D. Tell the client that she will feel better soon.
Correct Answer: A
Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns