Nokea
The nurse is preparing to give an adult a subcutaneous injection of heparin. What should the nurse check prior to giving the medication?
- A. International normalized ratio (INR)
- B. Bleeding time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: D
Rationale: Partial thromboplastin time (PTT) monitors heparin's anticoagulant effect, ensuring safe administration by assessing bleeding risk.
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The mother is concerned that her 6-year-old child is eating dirt every day. The nurse is most concerned about which of the following?
- A. The child may not be getting enough to eat.
- B. The child may have lead poisoning.
- C. This is normal childhood behavior.
- D. The child may have iron deficiency anemia.
Correct Answer: B
Rationale: Pica, such as eating dirt, raises concern for lead poisoning, especially in children, as contaminated soil may contain lead, posing neurological risks.
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
- A. Speak directly to the interpreter while presenting information and use pauses for questions
- B. Talk to the interpreter in advance and leave the client and interpreter alone
- C. Include a family member and direct communications to that person
- D. Face the client while presenting the information as the interpreter talks in the native language
Correct Answer: D
Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.
A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.
The nurse has reinforced teaching with a client with newly diagnosed psoriasis. Which of the following statements by the client would require follow-up?
- A. Exposure to sunlight will worsen my psoriasis.
- B. I should avoid scratching the lesions.
- C. Stress can worsen my psoriasis.
- D. I should avoid drinking alcohol.
Correct Answer: A
Rationale: Moderate sunlight exposure can improve psoriasis, so statement A is incorrect and requires follow-up. Avoiding scratching (B), recognizing stress as a trigger (C), and avoiding alcohol (D) are accurate and align with psoriasis management.
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
- A. Chest x-ray
- B. Blood culture
- C. Sputum culture
- D. PPD intradermal test
Correct Answer: D
Rationale: PPD intradermal test. The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.