Nokea
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
- A. Administer the dose as ordered.
- B. Hold the dose and notify the physician.
- C. Administer half the prescribed dose.
- D. Administer vitamin K as an antidote.
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.
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A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?
- A. Apply petroleum jelly around the stoma daily.'
- B. Clean the area with alcohol wipes before applying the pouch.'
- C. Ensure the skin barrier fits snugly and clean with mild soap.'
- D. Change the pouch only once a week.'
Correct Answer: C
Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.
Which is most closely aligned with ethics?
- A. Morals
- B. Laws
- C. Statutes
- D. Client rights
Correct Answer: A
Rationale: Ethics is most closely aligned with morals , as both involve principles of right and wrong that guide behavior, whereas laws and statutes are legal frameworks, and client rights are specific entitlements.
A nurse is teaching a client about crutch walking. Which of the following instructions should the nurse include?
- A. Bear weight on the axillae
- B. Keep elbows extended while walking
- C. Place crutches 6–10 inches to the side and front
- D. Step with the affected leg first
Correct Answer: C
Rationale: Crutches should be placed 6–10 inches to the side and front for stability. Weight is borne on hands, elbows are flexed, and the unaffected leg steps first.
When a client of Mexican American descent tells the nurse that she treated her infection by drinking milk, the nurse interprets the client's remark as:
- A. Confusion from fever
- B. Use of the first disease concept
- C. Use of milk as a laxative
- D. The need for a dietitian to assist her with meal planning
Correct Answer: B
Rationale: In Mexican American culture, milk may be used as a traditional remedy for certain conditions, reflecting the ‘hot-cold' disease concept. It's not necessarily confusion, a laxative, or a dietary issue.
The nurse is caring for a client with a history of hyperthyroidism who is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hypertension.
- C. Hyperglycemia.
- D. Weight loss.
Correct Answer: A
Rationale: Methimazole can cause agranulocytosis, a serious reduction in white blood cells, requiring monitoring.