Nokea
The nurse is caring for a client with a history of a pulmonary embolism who is receiving Lovenox (enoxaparin). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Enoxaparin, a low-molecular-weight heparin, increases bleeding risk, requiring monitoring for signs like bruising or hematuria. Hypertension, tachypnea, and fever are not primary concerns.
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The nurse is teaching a client with a history of hyperlipidemia about dietary modifications. The nurse should tell the client to avoid:
- A. Saturated fats
- B. Lean proteins
- C. Complex carbohydrates
- D. Fresh fruits
Correct Answer: A
Rationale: Saturated fats increase LDL cholesterol, worsening hyperlipidemia, so they should be avoided to reduce cardiovascular risk.
A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
- A. Reinforce the dressing.
- B. Continue to monitor the dressing.
- C. Notify the physician.
- D. Note the time and amount of blood.
Correct Answer: C
Rationale: The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. Blood on the dressing is unusual and requires prompt action to assess and manage potential complications.
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Teach mother poison prevention techniques.
- D. Place child on respiratory assistance.
Correct Answer: A
Rationale: The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. The mother's anxiety is probably so high that preventive guidance will be ineffective. Respiratory assistance is not needed if the child's respiratory function is unaltered.
The nurse is caring for a client post-colonoscopy. Which finding requires immediate intervention?
- A. Mild abdominal cramping
- B. Bright red blood in the stool
- C. Slight drowsiness
- D. Flatulence
Correct Answer: B
Rationale: Bright red blood in the stool suggests post-colonoscopy bleeding, possibly from perforation, requiring immediate intervention. Cramping (A), drowsiness (C), and flatulence (D) are expected.
The client presents to the emergency room with a hyphema. Which action by the nurse would be appropriate?
- A. Elevate the head of the bed and apply ice to the eye.
- B. Place the client in a supine position and apply heat to the knee.
- C. Insert a Foley catheter and measure the intake and output.
- D. Perform a vaginal exam and check for a discharge.
Correct Answer: A
Rationale: A hyphema (blood in the anterior chamber of the eye) requires elevating the head to reduce intraocular pressure and applying ice to decrease swelling. The other actions are irrelevant to hyphema management.