Nokea
The nurse is caring for a client who has been placed on a hypothermia blanket. What should the nurse include in the care plan?
- A. Take frequent vital signs and perform frequent skin assessments
- B. Leave the hypothermia blanket on until the client's temperature reaches 98.6°F
- C. Place the client directly on the blanket
- D. Apply iced alcohol sponges to the part of the client's trunk not in contact with the blanket
Correct Answer: A
Rationale: Frequent vital signs monitor for hypothermia or cardiovascular instability, and skin assessments prevent pressure injuries or cold burns. Direct blanket contact, prolonged use, or alcohol sponges risk skin damage or ineffective cooling.
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The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
- A. Eat large amounts of rice.
- B. Increase the amount of fruits and vegetables in your diet.
- C. Ask the doctor for a prescription for a drug such as diphenoxylate hydrochloride and atropine sulfate (Lomotil).
- D. Drink fluids only with meals.
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.
An adult has experienced significant vomiting and diarrhea for the past 24 hours. Her chloride level is 90 mEq/L. What would the nurse expect to find when interpreting her sodium level?
- A. It would be high.
- B. It is impossible to predict the sodium level with this information.
- C. It would be low.
- D. It would be normal.
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, likely resulting in a low sodium level, consistent with a low chloride level.
The physician orders naproxen sodium (Anaprox) 250 mg enteric-coated tablets PO bid for a 45-year-old man.
Which response, if made by the client, would indicate that the nurse's teaching about the medication has been effective?
- A. I can join my wife in a glass of wine with our dinner when we eat in a restaurant.'
- B. I should avoid milk and dairy products when I take this pill.'
- C. I should call my doctor if my stools turn very dark.'
- D. I don't like to take pills so I will crush the pill and add it to some applesauce.'
Correct Answer: C
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a true statement. (1) alcohol increases risk of GI bleeding (2) should be taken with food, milk, or antacid to decrease GI upset (3) correct-NSAIDS can cause GI bleeding (4) enteric-coated tablet should not be broken
A client who has a strong family history of breast cancer tells the nurse that she is taking a drug to prevent breast cancer. The nurse expects the drug that she is receiving is:
- A. Tamoxifen (Nolvadex)
- B. Cyclophosphamide (Cytoxan)
- C. Estrogen (Premarin)
- D. Doxorubicin (Adriamycin)
Correct Answer: A
Rationale: Tamoxifen is used for breast cancer prevention in high-risk individuals due to its anti-estrogenic effects. Cyclophosphamide and Doxorubicin are chemotherapy drugs, not preventive, so B and D are incorrect. Estrogen can increase breast cancer risk, making C incorrect.
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication