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The nurse is caring for a client with a history of venous thromboembolism who is prescribed rivaroxaban (Xarelto). 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 rivaroxaban, requiring immediate reporting.
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A client with a diagnosis of gout is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking allopurinol with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Drainage of 50 mL/hour
- D. Secured dressings around the tube site
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
- A. Give higher doses of pain medication.
- B. Keep patches on the client's eyes to prevent corneal abrasion.
- C. Monitor the temperature of the bathwater.
- D. Avoid turning the client.
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
Which of these statements related to information technology is accurate?
- A. Social networks and cell phone cameras pose low risk in terms of information technology security and confidentiality.
- B. The security of technological data and information in healthcare environments is most often violated by those who work there.
- C. The security of technological data and information in healthcare environments is most often violated by computer hackers.
- D. Computer data deletion destroys all evidence of the data.
Correct Answer: B
Rationale: The most common breaches of healthcare data security occur internally by staff , through actions like unauthorized access or improper handling of information, rather than external hackers or low-risk social media . Data deletion does not always destroy all evidence.
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?
- A. Hold the lithium and obtain a stat lithium level to determine therapeutic effectiveness.
- B. Continue the lithium and immediately notify the physician about the assessment findings.
- C. Continue the lithium and reassure the client that these temporary side effects will subside.
- D. Hold the lithium and monitor the client for signs and symptoms of increasing toxicity.
Correct Answer: C
Rationale: These symptoms are common side effects of lithium, especially early in treatment, and typically subside as the body adjusts. Continuing the medication and reassuring the client is appropriate unless symptoms worsen.