Nokea
The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?
- A. I can come back at the end of my shift when I am able to stay longer.
- B. I will ask a friend or family member to stay with you if you would like.
- C. I can stay and sit with you for a short time if you would like.
- D. I will contact the chaplain to sit with you and your spouse
Correct Answer: C
Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.
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Discharge medications
Aspirin: 81 mg by mouth, once daily
Clopidogrel: 75 mg by mouth, once daily
Rivaroxaban: 20 mg by mouth, once daily
Metoprolol: 25 mg by mouth, twice daily
Rosuvastatin: 20 mg by mouth, once daily
Lisinopril: 10 mg by mouth, once daily
A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority to reinforce for this client?
- A. Bleeding risk
- B. Bronchospasm
- C. Muscle injury
- D. Tinnitus
Correct Answer: A
Rationale: Anticoagulants/antiplatelets for CAD/AF increase bleeding risk , the highest priority. Bronchospasm , muscle injury , and tinnitus are less relevant.
A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?
- A. Atenolol is an iodine-based medication that blocks the release of thyroid hormones.
- B. It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate.
- C. This medication is radioactive and damages or destroys the thyroid tissue.
- D. This first-line antithyroid drug inhibits the synthesis of thyroid hormones
Correct Answer: B
Rationale: Atenolol is a beta-blocker that controls hyperthyroidism symptoms like tachycardia. It is not iodine-based , radioactive , or an antithyroid drug .
The nurse is caring for a client receiving Theodur (theophylline). Side effects associated with bronchodilators include:
- A. Irritability, rapid pulse, and palpitations
- B. Slow pulse, increased appetite, and sweating
- C. Anxiety, nausea, and increased blood pressure
- D. Drowsiness, vomiting, and decreased blood sugar
Correct Answer: A
Rationale: Theophylline can cause irritability, rapid pulse, and palpitations due to its stimulant effects. Slow pulse , drowsiness , or decreased blood sugar are not typical.
A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A. A home health patient reports, 'I am starting to have breakdown of my heels.'
- B. A patient that received an upper extremity cast yesterday reports, 'I can't feel my fingers in my right hand today.'
- C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
- D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Correct Answer: B
Rationale: The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.
After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?
- A. Client rates leg pain as '7'
- B. Negative Homan sign
- C. Prominent varicose veins bilaterally
- D. Right calf is 4 cm larger than left calf
Correct Answer: D
Rationale: Calf asymmetry of 4 cm suggests deep vein thrombosis, a critical postoperative complication. Pain is nonspecific, negative Homan sign is unreliable, and varicose veins are less urgent.