Nokea
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously q12h. The nurse should monitor for which of the following as a side effect?
- A. Increased urine output.
- B. Bruising at the injection site.
- C. Elevated blood pressure.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Heparin can cause bruising at injection sites due to its anticoagulant effect. Options A, C, and D are not typical side effects.
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The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication?
- A. Nausea.
- B. Visual disturbances.
- C. Tinnitus.
- D. Ataxia.
Correct Answer: A
Rationale: common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence
A client with chronic obstructive pulmonary disease is receiving $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$ via nasal cannula. He is anxious and short of breath, and his mental status is clouded. The nurse should:
- A. Increase the $\mathrm{O}_2$ to $6 \mathrm{~L}/\mathrm{min}$.
- B. Monitor for signs of impending respiratory failure.
- C. Maintain the $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$, but increase the humidity.
- D. Check the vital signs and oxygen saturation level.
Correct Answer: D
Rationale: Checking vital signs and oxygen saturation assesses the cause of symptoms (e.g., hypoxia, hypercapnia). Increasing O2 risks CO2 retention in COPD. Monitoring is passive. Humidity is secondary.
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
- A. When a family member offers information about their loved one
- B. When the client threatens self-harm and harm to others
- C. When the provider requests a copy of the client's history
- D. When a visitor insists that the visitor has been given permission by the client
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
- A. Increased retention of albumin in the vascular system
- B. Decreased colloidal osmotic pressure in the capillaries
- C. Fluid shift from interstitial spaces into the vascular space
- D. Reduced tubular reabsorption of sodium and water
Correct Answer: B
Rationale: Decreased colloidal osmotic pressure in the capillaries. Loss of albumin reduces osmotic pressure, causing edema.
The nurse is preparing to discharge a client with a new diagnosis of asthma.
- A. What is the most important teaching point for a client with a new asthma diagnosis?
- B. Use a spacer with the metered-dose inhaler.
- C. Take the bronchodilator before the corticosteroid.
- D. Avoid exercise to prevent asthma attacks.
- E. Monitor peak flow readings daily.
Correct Answer: D
Rationale: Daily peak flow monitoring helps the client detect early changes in lung function, enabling timely intervention to prevent asthma exacerbations. Using a spacer, proper medication sequencing, and exercise management are important but secondary to ongoing monitoring.