Nokea
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Hypothermia
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect. Hypothermia (B), nausea (C), and hyperactivity (D) are not associated with clopidogrel.
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Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
- A. A 28-year-old with a history of alcohol use during the pregnancy
- B. A 24-year-old with a history of diabetes mellitus
- C. A 30-year-old with a history of smoking during the pregnancy
- D. A 32-year-old with a history of pregnancy-induced hypertension
Correct Answer: B
Rationale: Maternal diabetes increases the risk of neonatal respiratory distress syndrome due to impaired surfactant production from hyperglycemia. Alcohol, smoking, and hypertension are less directly linked.
The physician has ordered 50 mEq of potassium chloride for a client with a potassium level of 2.5 mEq/L. The nurse should administer the medication:
- A. Slow, continuous IV push over 10 minutes
- B. Continuous infusion over 30 minutes
- C. Controlled infusion over five hours
- D. Continuous infusion over 24 hours
Correct Answer: C
Rationale: Potassium chloride for hypokalemia (2.5 mEq/L) should be administered via controlled IV infusion over several hours (e.g., five hours) to prevent rapid shifts that could cause arrhythmias.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John's wort seldom relieves depression.
- B. She should avoid eating aged cheese.
- C. Skin reactions increase with the use of sunscreen.
- D. The herbal is safe to use with other antidepressants.
Correct Answer: C
Rationale: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.'
- B. If I have any side effects from my medicines, I will take an extra dose of Cogentin.'
- C. When I get home, I should be able to taper myself off the Haldol because the voices are gone now.'
- D. As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway.'
Correct Answer: A
Rationale: The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. This statement reflects lack of insight into the importance of compliance. This statement reflects no insight into his illness or his responsibility in health maintenance.
A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
- A. Pneumonia
- B. Pulmonary contusions
- C. Pulmonary edema
- D. Tension pneumothorax
Correct Answer: B
Rationale: Pulmonary contusions from blunt chest trauma cause alveolar edema and hemorrhage, leading to bloody sputum, hypoxemia, and patchy infiltrates on x-ray.