Nokea
The nurse is planning care for a client with a prescription for anticoagulant agents. Which should the nurse identify as a potential concern for this client?
- A. Fatigue
- B. Bruising
- C. Infection
- D. Dehydration
Correct Answer: B
Rationale: Anticoagulant therapy predisposes the client to injury because of the agent's inhibitory effects on the body's normal blood-clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of activities of daily living and with other activities. Options 1, 3, and 4 are unrelated to this form of therapy.
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A client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the UAP that which intervention is needed for infection control?
- A. Enteric precautions should be instituted for the client.
- B. Gloves and mask should be used when in the client's room.
- C. Contact isolation should be initiated because the disease is highly contagious.
- D. Standard precautions are sufficient because the disease is transmitted sexually.
Correct Answer: D
Rationale: Chlamydia is a sexually transmitted infection. Caregivers cannot acquire the disease during administration of care, and standard precautions are the only measure that needs to be used. Recognizing the necessary precautions will help you in identifying the remaining options as incorrect.
The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next?
- A. Inflate the balloon with water.
- B. Secure the catheter to the client.
- C. Measure the initial urine output.
- D. Advance the catheter 2.5 to 5cm .
Correct Answer: D
Rationale: The balloon of a urinary catheter is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5cm further after urine begins to flow so as to provide sufficient space to inflate the balloon. The balloon is not inflated as soon as urine appears because the balloon could be located in the urethra. After the insertion procedure and inflation of the balloon, the nurse secures the catheter to the client's leg and then measures the initial urine output.
The nurse observes that a postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to prevent escalating the agitation?
- A. Gently hold the client's hand while speaking.
- B. Wait to approach until the client's agitation has subsided.
- C. Speak in a calm tone while moving slowly toward the client.
- D. Communicate with the client from the entrance to the room.
Correct Answer: C
Rationale: Speaking and moving slowly toward the client will prevent the client from becoming further agitated because any sudden moves or speaking too quickly may cause the client to have a violent episode. Holding the client's hand can be misinterpreted by a client to mean restraint. If the client's agitation is not addressed, it is likely to increase; therefore, waiting for the agitation to subside is not a suitable option. Remaining at the entrance of the room can make the client feel alienated.
The nurse notes that a client's lithium level is 3.9 \mathrm{mEq} / \mathrm{L}(3.9 \mathrm{mmol} / \mathrm{L}) . Based on this data, which priority intervention should the nurse implement?
- A. Determining visual acuity
- B. Assisting with ambulation
- C. Monitoring intake and output
- D. Instituting seizure precautions
Correct Answer: D
Rationale: The lithium level must be monitored closely in a client taking lithium. A therapeutic regimen is designed to attain a serum lithium level of 0.8 to 1.2 \mathrm{mEq} / \mathrm{L}(0.8 to 1.2 \mathrm{mmol} / \mathrm{L}) for maintenance treatment. A level of 3.9 \mathrm{mEq} / \mathrm{L (3.9 \mathrm{mmol} / \mathrm{L}) is in the toxic range, and seizures may occur at levels of 3.5 \mathrm{mEq} / \mathrm{L (3.5 \mathrm{mmol} / \mathrm{L}) and higher. While the remaining options are appropriate interventions, they are not the priority because they are not related to the possibility of toxicity.
The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to implement initially?
- A. Reassign the coworker to the care of clients not receiving opioids.
- B. Notify the primary health care provider that the client needs an increase in opioid dosage.
- C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor.
- D. Confront the coworker with the information about the client having pain control problems and ask if the coworker is using the opioids personally.
Correct Answer: C
Rationale: In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. To reassign the coworker to clients not receiving opioids ignores the issue. The client does not need an increase in opioids. A confrontation is not the most advisable action because it could result in an argumentative situation.