Nokea
The nurse is preparing to administer a scheduled vaccine to a pediatric client with hemophilia. Which of the following actions should the nurse take? Select all that apply.
- A. Administer ibuprofen for pain relief.
- B. Apply a warm compress to the injection site.
- C. Hold firm pressure to the injection site for 5 minutes.
- D. Massage the injection site to disperse the medication.
- E. Use the smallest bore and shortest needle length indicated.
Correct Answer: C,E
Rationale: Firm pressure for 5 minutes (C) and using a small, short needle (E) minimize bleeding in hemophilia. Ibuprofen (A) increases bleeding risk, warm compresses (B) may worsen bleeding, and massage (D) can cause hematoma.
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The nurse is talking with a client who has a new prescription for misoprostol to prevent gastric ulcers. Which of the following statements by the client would require follow-up?
- A. I will take this medication with meals and at bedtime.
- B. I plan to use a reliable form of birth control while taking this medication.
- C. I can take this medication with an antacid to prevent an upset stomach.
- D. I should notify my health care provider if I develop black, tarry stools while taking this medication.
Correct Answer: C
Rationale: Taking misoprostol with antacids (C) reduces its efficacy and requires follow-up. Taking with meals (A), using contraception (B), and reporting black stools (D) are correct.
A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.
- A. Palliative care focuses on quality of life and can be provided at any time
- B. Palliative care is only possible with a terminal diagnosis of ≤ 6 months
- C. Palliative care is provided by a multidisciplinary team
- D. Palliative care is another term for hospice care
- E. Palliative care provides relief from symptoms associated with chronic illnesses
Correct Answer: A,C,E
Rationale: Palliative care aims to improve quality of life and can be provided at any stage of illness (A). It involves a multidisciplinary team to address various needs (C). It also focuses on symptom relief for chronic illnesses (E). Palliative care is not limited to terminal diagnoses (B is incorrect) and is distinct from hospice care, which is specifically for end-of-life (D is incorrect).
The nurse is planning an approach to decrease urinary incontinence in an elderly client. Which activity will do the most to help prevent incontinence?
- A. Restrict fluids until continence has been achieved and then hydrate well.
- B. Offer the bedpan at two-hour intervals during the day and every four hours at night.
- C. Encourage the client to ambulate frequently and have the client do deep breathing exercises.
- D. Encourage fluids during the day and offer the bedpan every two hours.
Correct Answer: D
Rationale: Adequate hydration and frequent toileting (every two hours) promote bladder health and reduce incontinence. Fluid restriction or unrelated exercises are ineffective.
An adult is prescribed sulfisoxazole (Gantrisin) for a urinary tract infection. Which comment by the client indicates understanding of the treatment regimen?
- A. When I feel better, I can stop taking the medicine.
- B. I will stay out of the sun when I am taking this drug.
- C. I should restrict fluids during the evening as long as I am on the medicine.
- D. I will bring in a urine specimen every day while I am taking the drug.
Correct Answer: B
Rationale: Sulfisoxazole causes photosensitivity; avoiding sun exposure is critical to prevent skin reactions, indicating understanding.
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
- A. Auscultate the client's breath sounds
- B. Encourage the client to increase fluid intake
- C. Report the findings to the supervising registered nurse
- D. Start an IV line for diuretic administration
Correct Answer: C
Rationale: Low urine output (200 mL/8 hr) in heart failure suggests worsening fluid retention, requiring immediate reporting to the RN (C). Auscultation (A), fluids (B), and IV diuretics (D) require RN direction.