Nokea
The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?
- A. Estrogen replacement therapy
- B. 10% less than ideal body weight
- C. Hypersensitivity to heparin
- D. History of hepatitis
Correct Answer: A
Rationale: Estrogen increases the hypercoagulability of the blood and increases the risk for development of thrombophlebitis.
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While sitting in the cafeteria, a nurse overhears two students discussing a client admitted for chemical detoxification. The nurse should:
- A. Report the incident to the teacher.
- B. Report the incident to the nursing supervisor.
- C. Confront the students with their behavior.
- D. Ignore the students' behavior.
Correct Answer: C
Rationale: Confronting the students addresses the breach of confidentiality directly and educates them. Reporting to the teacher or supervisor escalates unnecessarily, and ignoring the behavior allows the violation to persist.
The nurse is collecting data on a client with hypertension and essential tremor who received the first dose of propranolol 2 hours ago. Which assessment is most concerning to the nurse?
- A. Client reports a headache
- B. Current blood pressure is 160/88 mm Hg
- C. Heart rate has decreased from 70/min to 60/min
- D. Slight wheezes auscultated during inspiration
Correct Answer: D
Rationale: Wheezing post-propranolol is concerning for bronchospasm, a serious side effect in a patient with no known respiratory history. Headache , elevated BP , and mild heart rate decrease are less urgent.
A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor?
- A. Discourages the client from rubbing the injection site
- B. Ejects air bubble that is in the syringe prior to administration
- C. Inserts needle and injects medication at a 90-degree angle
- D. Selects an injection site on the left lateral side of the abdomen
Correct Answer: B
Rationale: Ejecting the air bubble in an enoxaparin syringe is incorrect, as the bubble ensures complete dose delivery and prevents leakage. Other actions (A, C, D) are correct for subcutaneous administration.
A client is scheduled for a myelogram. Which of the following medications orders should be questioned?
- A. Ampicillin (Pencipen) $250 \mathrm{mg} \mathrm{PO} \mathrm{q} 6$ hours
- B. Motrin (Ibuprofen) $400 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours PRN for headache
- C. Secobarbital (Seconal) $50 \mathrm{mg}$ HS PRN for sleep
- D. Propoxyphene (Darvon) $65 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours for pain
Correct Answer: B
Rationale: Ibuprofen (Motrin) has anticoagulant properties, increasing bleeding risk during a myelogram, a procedure involving spinal puncture. Other medications are safer.
The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?
- A. cyanosis
- B. muffled heart tones
- C. murmur
- D. weak femoral pulses
Correct Answer: C
Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.