Nokea
The nurse is caring for a client with a history of atrial fibrillation who is prescribed apixaban (Eliquis). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with apixaban, requiring immediate reporting.
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You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are typically documented as length x width x depth (2 cm x 4 cm x 3 cm), but based on options, 12 cm may reflect a calculation error; correct documentation is individual measurements.
A 30-week-gestation client admitted in preterm labor is prescribed betamethasone. What should the nurse tell the client is the purpose for this medication?
- A. Promote fetal lung maturity.
- B. Delay delivery for at least 48 hours.
- C. Stop the premature uterine contractions.
- D. Prevent premature closure of the ductus arteriosus.
Correct Answer: A
Rationale: Betamethasone, a corticosteroid, is administered to increase the surfactant level and increase fetal lung maturity, reducing the incidence of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks' gestation. If adequate amounts of surfactant are not present in the lungs, respiratory distress and death are possible consequences. Delivery needs to be delayed for at least 48 hours after the administration of betamethasone in order to allow time for the lungs to mature. The remaining options are incorrect.
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: B
Rationale: Raising the side rails ensures client safety, preventing falls, especially if the client is attempting to sit up.
During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.
Which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
- A. Partial thromboplastin time
- B. Potassium level
- C. Lee-White clotting time
- D. Fibrin split product
Correct Answer: A
Rationale: Partial thromboplastin time (PTT) is essential before administering alteplase to assess bleeding risk, as it is a thrombolytic. Potassium levels and other tests are less relevant in this context.