Nokea
The nurse is caring for a client with a history of deep vein thrombosis who is prescribed enoxaparin (Lovenox). 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 enoxaparin, requiring immediate reporting.
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Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
A nurse is preparing to administer 500 mL of an I.V. solution to a child over 12 hours via tubing that delivers microdrips at 60 gtt/mL. At what rate should the nurse infuse the solution?
- A. 42 gtt/minute.
- B. 83 gtt/minute.
- C. 60 gtt/minute.
- D. 21 gtt/minute.
Correct Answer: A
Rationale: Calculate: 500 mL over 12 hours = 41.67 mL/hour. For microdrip (60 gtt/mL), 41.67 mL/hour ×60 gtt/mL = 2500 gtt/hour ÷ 60 minutes = 41.67 gtt/minute, rounded to 42 gtt/minute.
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
- A. Ensured the client's safety which is a high patient care priority
- B. Violated Respondeat Superior
- C. Violated the client's right to dignity
- D. Committed a crime
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.