Nokea
The nurse is preparing to administer scheduled medications to assigned clients. Which of the following medications should the nurse hold for clarification prior to administering?
- A. magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.41 mmol/L)
- B. calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L)
- C. clopidogrel for a client with a platelet count of 70,000/mm³ (70 × 10â¹/L)
- D. metformin for a client with a hemoglobin A1c level of 11%
Correct Answer: C
Rationale: Clopidogrel increases bleeding risk in a client with low platelets (70,000/mm³), requiring clarification. The other medications align with the clients' conditions.
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The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
- A. I will hold the cane in my right hand.
- B. I will advance the cane and the right leg together.
- C. I will be able to walk only by using a walker.
- D. I will hold the cane in my left hand.
Correct Answer: D
Rationale: For right-sided hemiplegia, the cane is held in the left hand to support the weaker right side. Holding it in the right hand or advancing it with the right leg is incorrect. A walker is not always necessary.
An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?
- A. Apical heart rate is 62/min
- B. Blood sugar level is 240 mg/dL (13.3 mmol/L)
- C. Client is taking 20 mg fluoxetine daily
- D. Serum creatinine is 2.3 mg/dL (203 µmol/L)
Correct Answer: D
Rationale: Elevated serum creatinine (2.3 mg/dL) indicates renal impairment, which can lead to digoxin accumulation, necessitating frequent monitoring.
An adult who had a mastectomy yesterday says to the nurse, 'I guess I'm not a real woman anymore. How could my husband possibly love me now?' What is the best response for the nurse to make?
- A. You don't feel like a woman now?'
- B. Has your husband said anything to you?'
- C. Of course your husband will love you.'
- D. True love is not dependent on breasts.'
Correct Answer: A
Rationale: Reflecting the client's feelings validates her emotional distress, fostering therapeutic communication post-mastectomy. Other responses dismiss or redirect her concerns.
The nurse is talking with a client with a brain tumor who has a new prescription for levetiracetam. Which of the following statements would be appropriate for the nurse to make?
- A. The medication will prevent blood clots in your legs.
- B. The medication will decrease the size of your tumor.
- C. The medication helps prevent seizures from occurring.
- D. The medication helps decrease swelling around your tumor.
Correct Answer: C
Rationale: Levetiracetam is an anticonvulsant used to prevent seizures, a common complication in brain tumor patients.
The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what?
- A. React anxiously to altered daily routines
- B. Realize that death eventually affects everyone
- C. Think about the religious or spiritual aspects of death
- D. Understand that death is permanent but be curious about it
Correct Answer: D
Rationale: School-aged children (around 8 years old) typically understand death's permanence and may exhibit curiosity about it, which can guide coping strategies. A is more common in younger children. B and C are more typical of adolescents, who have more abstract thinking.